PATIENTS REPORT OF ACCIDENT
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- Shanna Brown
- 10 years ago
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1 Today s date: PATIENTS REPORT OF ACCIDENT (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: / / M F Home phone no: ( ) Cell phone no: ( ) Street address: Address: P.O. box: City: Province: Postal Code: Chose clinic because/referred to clinic by (please check one box): Dr. Family Friend Close to home/work Yellow Pages Other Other family members seen here: Insurance Plan Hospital ACCIDENT INFORMATION of Accident: Time of Accident: Accident Location: / / Were You: Driver Passenger Pedestrian Cyclist Were you wearing a seatbelt? How did the accident occur? Did the police attend? Have you been treated anywhere else for this accident? If yes, please name the treatment center: Have you been in any previous accidents? If yes, please provide the dates: Are You: Employed Unemployed Retired Student Homemaker Are you off work because of your accident? IN CASE OF EMERGENCY Name of local friend or relative : Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) The above information is true to the best of my knowledge: Patient/Guardian signature
2 (Please Print) Name of Employer: EMPLOYER INFORMATION Contact: Address: Employer Phone: ( ) Occupation: Do you have Group Benefits? If yes, please fill in this section: Group Benefits Insurance company Name: Address: Phone : ( ) Fax : ( ) Name of Insured: Plan : Group : Policy : Name of Automobile Insurance: AUTO INSURANCE INFORMATION Address: Phone : ( ) Fax : ( ) Adjusters Name: Policy : Claim : Name of Insured: Doctors Name: REFERRING PHYSICIAN INFORMATION Address: Phone : ( ) Fax : ( ) Firms Name: PARALEGAL/LAWYER S INFORMATION Representative: Address: Phone : ( ) Fax : ( )
3 Motor Vehicle Accident Patients Dear Patient: After experiencing a Motor Vehicle accident, we at vo Healthnet Limited know that the process can be overwhelming, so we have decided to provide some general but important information for this process and what you can expect from your vo Healthnet Limited team: - You will receive a package from your car Insurance. This package is called Accident Benefits Package and/or OCF1. This package must be completed and sent to your Insurance within 30 days of you receiving it. Before you send it off, please provide a copy to your attending vo Healthnet Limited location so we can keep a copy in your file in case your adjuster has any future questions. - If you do not have all your Insurance information at the time of your assessment you are to provide this on your 2 nd visit. This information includes your policy number, claim number, adjuster name and insurance company name. - By law, patients must provide any attending Clinic with their Extended Health Benefits (EHC/Work Benefits/Group Benefits/Private Insurance) information. - vo Healthnet Limited will ask you to pre-sign Claim forms so that we can submit to your Extended Health Carrier twice a month for reimbursement. After approximately 2 weeks of our submission, you will receive payment from your Extended Health carrier by mailed cheque or direct deposit. You are responsible to then forward payment and statement to your attending location. (Without this, we cannot submit to your Auto Insurance for the remaining balance.) - If you do not provide all the necessary or correct information, you will then be held responsible for any monies outstanding on your account. If you have any questions or concerns, please do not hesitate to ask our staff. Patient Signature Administrator Signature
4 IRREVOCABLE DIRECTION AND AUTHORIZATION I, understand that vo Healthnet Limited will submit to my insurance carrier, invoices related to treatment received at the clinic and I agree to provide vo Healthnet Limited with all necessary insurance documents and information. I hereby irrevocably direct my insurer to make all payments for treatments received by me to vo Healthnet Limited and this shall be its good and sufficient authority to do so. I agree that in the event that my insurer shall remit payment for such treatments directly to me, I shall forward such payments immediately vo Healthnet Limited In this regard I understand that I will be personally responsible to remit the payment to vo Healthnet Limited. In the event that my insurer should refuse to make payments for my treatments to vo Healthnet Limited, I agree that vo Healthnet Limited shall have the right in my name and on my behalf to take whatever legal proceeding it may deem necessary to collect payment for such treatments. I agree to fully cooperate with vo Healthnet Limited to provide any required documents and to attend at my mediation or arbitration hearings as would be necessary. In the event I should refuse to cooperate as noted I shall pay to vo Healthnet Limited including the costs of such treatment, all costs related to any such legal proceeding, mediation, or arbitration. Patient's Signature Witness
5 NOVO HEALTHNET LIMITED REHABILITATION AND WELLNESS DIVISION PHYSIOTHERAPIST, REHABILITATION and MASSAGE THERAPIST INFORMED CONSENT As a matter of ethics and law there is an obligation, prior to examination and treatment, to disclose any material risk to the patient in order to obtain a valid informed consent. As part of the physiotherapy, chiropractic and massage treatments, certain procedures and devices may be utilized such as the use of heat, ice, electrotherapy, ultrasound, massage and manual therapy. As part of the rehabilitation program (kinesiologist, occupational therapist or physical therapist assistant) certain testing procedures, devices and equipment may be utilized such as weight machines, exercise, cardiovascular work and functional tasks. I have had the opportunity to discuss with the doctor of chiropractic/physiotherapist and/or other clinical staff, the nature and purpose of treatments. I understand the results are not guaranteed. I further understand and I am informed that there are some very slight risks to treatments, including, but not limited to, muscle strains, sprains, disc injuries, and burns have been made aware that there are remote chances of injury and that appropriate tests will be performed to help identify if I may be susceptible to risk or injury. I have read and understood the above statement, accept the risk and hereby consent to treatment. Patient Signature: Witness Signature: _ : : CHIROPRACTIC INFORMED CONSENT (FORM L) There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic. In particular you should note: a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures; b) There are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke. Recent studies suggest that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occurring in association with upper cervical adjustment is extremely remote; c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment; d) There are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy offered by some doctors of chiropractic. I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this Consent. I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal adjustments. I intend this consent to apply to all my present and future chiropractic care. Patient Signature: Parent/Guardian Signature: Witness Signature: _ : : :
6 CONSENT AND AUTHORIZATION FOR RELEASE/LOAN OF MEDICAL INFORMATION/DIAGNOSTIC MATERIAL I, do hereby give my written permission and authorization to vo Healthnet Limited to communicate on my behalf, release and share information regarding my health and progress, for the purpose of determining my functional abilities for developing and implementing a functional rehabilitation program. I give permission to the following to provide and receive information pertaining to my medical condition. This consent may be revoked in writing at any time. Any such revocation shall have no effect on disclosures made prior to the date of revocation is received. I UNDERSTAND THAT I HAVE THE RIGHT TO INSPECT AND COPY THE INFORMATION TO BE DISCLOSED. Patient Signature: Parent/Guardian Signature: Witness Signature: _ : : :
7 PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q) Name: For most people physical activity should not pose any problem or hazard. The Par-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate for or for those who should have a medical concern regarding the type of activity most suited to their needs. Common sense is your best guide in answering the following questions. Please read them carefully and check or for each question. If you checked and feel the need to elaborate please use the designated space below the question to give additional details. 1. Has a doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? 2. Do you feel pain in your chest when you do any physical activity? 3. In the past month have you had any chest pain when you were not performing any physical activity? 4. Do you lose your balance because of dizziness or have you ever lost consciousness? 5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? 6. Is your Doctor currently prescribing drugs (ex: water pills) for your heart condition or any high blood pressure? 7. Do you know of any other reason why you should not do any physical activity? 8. Do you currently participate in any regular activity/program designed to improve or maintain your physical fitness? If yes, please indicate what type of program or activity. 9. If you suffer a cardiac arrest or rendered unconscious in our facility, would you consent for a certified CPR Clinician to perform emergency procedures?
8 Please indicate any of the following conditions you have: Arthritis Diabetes Thyroid Condition Dizziness/Fainting Low/High Blood Pressure Heart Condition Chest Pain Pacemaker History of Cancer Allergies to Tape/Latex Any Allergies Epilepsy/Seizures Shortness of Breath Asthma Bronchitis Other Respiratory Condition Hearing Impairment Pregnancy Metal Implants (Incl IUD) YES NO YES NO Hernia Depression Osteoporosis Smoking History Reynaud Sleeping Problems Cough Vision Difficulties Swallowing Difficulties Slurred Speech Memory Problems Balance Problems Recent Falls/Blackouts Unexplained Weight Loss/Gain Groin Numbness/Tingling Bowel & Bladder Difficulties Headaches Blood Diseases Other: SURGERIES: (please list) PREVIOUS INJURIES: DATES: INJECTIONS: (please list) DATES: _
9 NOTIFICATION FOR EXTENDED HEALTH COVERAGE PHYSIOTHERAPY COVERAGE Maximum coverage per calendar year: Maximum cost per treatment: Amount Remaining: MASSAGE COVERAGE Maximum coverage per calendar year: Maximum cost per treatment: Amount Remaining: CHIROPRACTIC COVERAGE Maximum coverage per calendar year: Maximum cost per treatment: Amount Remaining: ORTHOTICS COVERAGE Maximum coverage per calendar year: Maximum cost per treatment: Amount Remaining: Who can dispense (DC or PT): NATUROPATHIC/DIETICIAN COVERAGE Maximum coverage per calendar year: Maximum cost per treatment: Amount Remaining: ACUPUNCTURE COVERAGE Maximum coverage per calendar year: Maximum cost per treatment: Amount Remaining:
10 Achy or Constant Pain XXX Sharp Pain **** Mark the area on the picture below with the appropriate symbol to best illustrate your symptoms. Stiffness //// Numbness Other ooo
11 PATIENT REHABILITATION CONTRACT In order to ensure comprehensive and quality care, we believe that it is important that doctors, therapists and patients work together. The staff at vo Healthnet Limited are committed to making your recovery a positive experience and we require the same commitment from you, our patient. The following explains your obligation to this facility: Appointments should be made on a daily basis either for chiropractic, physiotherapy, massage, or exercise sessions. If you are unable to attend for treatments on a certain day for any reason, you are to call our clinic to cancel your appointment for that day and reschedule your next appointment. Please keep in mind that our priority is to our patients. However, we also have any obligation to your insurance company to report any absences or non compliance with the program. MOTIVATION: Your recovery depends on how hard you work. We will teach you what you must do in your rehabilitation, but you must be prepared to give us your best effort. This effort will be reflected in your progress. PROGRESS: Our program lasts approximately 8-10 weeks. We frequently re-assess your strength, flexibility and range of motion. In order to justify ongoing treatment, we must see significant improvements. If you are working hard your body will make physiological response and we will see improvement. YOUR RESPONSIBILITY: You must take an active role in your rehabilitation. If we do not see significant improvement, or if we feel that you are not committed to your recovery, ) i.e. poor attendance, and/or compliance), we reserve the right to discharge you from our facility. ATTENDANCE: Daily attendance is mandatory (unless otherwise specified). You are required to spend a minimum of initially. The amount of time you spend on your program will increase as you progress through each phase. If for any reason you are unable to attend on any given day, you must call the centre and inform us why you will not be in. If you are away for more than three days we require a medical note from your family physician. HOURS OF OPERATION: You must arrive at least 1 hour prior to closing time on any day. You will not be allowed to sign in if you are later then the above noted times.
12 SIGN-IN PROCEDURE: In order to ensure an accurate account of your attendance you must sign in at each visit. If your signature is not listed on the daily sheet, an absence will be recorded on your file. CLOTHING: Wear clothing that is appropriate for active movements such as easy fitting pants, t- shirts and running shoes. Use of the gym equipment is prohibited. You may change your shoes and/or clothing at the centre, however there are no storage facilities. SMOKING: The centre is a non-smoking facility. I, understand that the staff at vo Healthnet Limited share the ultimate goal of getting me well. I have read and understood the contents of the forementioned list and agree to comply to the best of my ability. I have received information on the program and understand the nature of the program and consent to it. Signature Witness
13 Informed Consent Form for Therapy Treatment of a Minor (under 18 years of age) I understand that I am responsible for any and all outstanding payments and fees related to this treatment. Patient Information First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Address: Sex: M F of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( ) Work Phone: ( ) Parent/Guardian Information First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Address: Sex: M F of Birth (mm/dd/yyyy): / / Relationship to Patient: Home Phone: ( ) Work Phone: ( ) Parent/Guardian Signature Witness
Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( )
Patient Information Date: First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone:
Do you have private medical insurance (i.e. Blue Cross, Sun Life, Great West Life)? Yes
PERSONAL INFORMATION: The information in this section has remained unchanged from my last visit with CORE Physiotherapy & Rehabilitation Centre Inc. Last Name: DOB: First Name: Health Card Number: Address:
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PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER
Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
X Guarantor/Parent/Guardian Signature
Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency
Insurance (Let us make a copy of your insurance card and you can skip this section)
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Shine Integrative Physical Therapy Intake Form First name Middle Last Birthdate / / How did you hear about us? Address City State Zip Home phone Cell phone Email address Occupation Emergency contact Phone
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