Patient Intake Form


  • For appointment confirmation
    If yes, please notify the receptionist.



    Please check below for any conditions that you are experiencing or have experienced.
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  • (fertility treatments, menopause, endometriosis)
  • (type and date)
  • Please let your therapist know immediately if any of the above answers change.

    We require 24 hours notice if you need to reschedule or cancel your appointment. If the appointment is not cancelled with proper notice, a fee of $38.00 will be charged to your account for a 30-minute appointment; a fee of $50.00 will be charged to your account for a 60-minute appointment.

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  • Informed Patient Consent To Care

    Prior to assessment and treatment, as a matter of ethics and law, there is an obligation to disclose any material risk to the patient in order to obtain valid informed consent. 

    The initial assessment contains an examination consisting of: postural analysis, physical examination, muscle testing and orthopedic/neurological examination. 

    After this initial assessment, examination findings will be interpreted and you will be given an oral report of findings and recommendations as to the rehabilitation treatment required in your particular case. If your condition would be best treated by another health discipline, you will be advised and referred accordingly. 

    As part of the treatments, certain procedures and devices may be utilized such as the use of heat, ice, electrotherapy, ultrasound, manual therapy and acupuncture. During your rehabilitation program you may be assisted by kinesiologists, physiotherapy assistants or students using certain testing procedures, devices and equipment such as weight machines, exercise, stretching, cardiovascular work and functional tasks. Your practitioners will exercise their professional judgement to do no harm during the course of the procedures, in that your best interest of health is always of primary importance. 

  • Patient consent to care

  • I understand I will have the opportunity to discuss with my health care provider and/or other clinical staff, the nature and purpose of treatments. I understand that results are not guaranteed. 

    I further understand and am informed that there are some very slight risks to treatments, including, but not limited to, muscle strain, sprains, disc injuries and bums. I 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. 

    By signing below I agree that I am informed of the potential risks and indicate my intention to participate in the course of diagnosis and treatment recommended by the practitioner. 

  • Patient Consent for the Collection, Use and Disclosure of Personal Information 

    Privacy of your personal information is an important part of Motion Matters Physiotherapy and Sports Injury Clinic, while providing you with quality treatment and care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information. 

    All staff members who come in contact with your personal information are aware of the sensitive nature of the personal information that you have disclosed to us. They are trained in the appropriate use and protection of your information. 

    Our privacy policy outlines what Motion Matters is doing to ensure that:

        Only necessary information is collected about you
        We only share your information with your consent
        Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols
        Our privacy protocols comply with privacy legislation and standards of our regulatory body, the Canadian Physiotherapy Association/ the Ontario College of Physiotherapists

    How our clinic collects, uses and discloses patient's personal information

    Motion Matters understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how Motion Matters is using and disclosing your information. The clinic will collect, use and disclose information about you for the following purposes: 

        To assess your health concerns
        To provide health care
        To advise you of treatment options
        To establish and maintain contact with you
        To send you newsletters and other mailings
        To remind you of upcoming appointments
        To communicate with other treating health care providers
        To allow us to efficiently follow-up for treatment, care and billing
        To complete claim forms for insurance purposes
        To invoice for goods and services
        To process credit card payments
        To collect unpaid accounts
        To comply with all regulatory and legal requirements including court orders, statutory requirements including to advise authorities of child abuse, reportable diseases and individuals who may be an imminent threat to harm themselves or others

    Patient consent for collection, use and disclosure of personal information

    I have reviewed the above information that explains how Motion Matters Physiotherapy and Sports Injury Clinic will use my personal information, and the steps that Motion Matters is taking to protect my information. I agree that Motion Matters can collect, use and disclose personal information about me as outlined above.

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