MJ Physio Virtual Care Patient Form

Name

DOB

Address

Cell Phone Number

Personal Health Number (PHN)

Emergency Contact Name

Emergency Contact Phone Number

Family Doctor / Clinic Name

Date

Patient Authorization -You consent to MJPhysio to collect, use and /or disclose any information that may benefit the practitioner with my assessment and treatment. I hereby authorize release of any requested medical information to my doctor/lawyer/employer/and third-party payer regarding injury and treatment, if applicable. I also hereby authorize MJPhysio to obtain any medical information required to assist with the therapy and Rehabilitation related to this injury.

Patient Authorization - You consent to MJPhysio to collect, use and /or disclose any information that may benefit the practitioner with my assessment and treatment. I hereby authorize release of any requested medical information to my doctor/lawyer/employer/and third-party payer regarding injury and treatment, if applicable. I also hereby authorize MJPhysio to obtain any medical information required to assist with the therapy and Rehabilitation related to this injury. *

Cancellation Policy - 24-hour notice must be given to change or cancel any appointment you have scheduled. Failure to do so will result in a fee applied to your account. I have read and understood the cancellation policy

Cancellation Policy - 24-hour notice must be given to change or cancel any appointment you have scheduled. Failure to do so will result in a fee applied to your account. I have read and understood the cancellation policy

Digital Signature of Patient (By typing in your name below you're signing on the above items)

I have read the patient consent form and agree to terms and conditions. I have read the consent to assess and treat form and I consent to assessment and treatment by physiotherapists at MJPhysio.
Read the patient consent form before signing: Read More

MJ Physio Virtual Care Patient Form

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Contact Information

MJ Physio - Fraser Street Physio

MJ Physio - Fleetwood