If you prefer to print off the Patient Intake Form and bring it to your appointment you can do so here.Step 1 of 250%Personal InformationCheck OneSelect...Mr.Mrs.MissMs.Dr.Rev.GenderSelect...MaleFemaleName* First Last Email Phone*Work PhoneAlt PhoneOccupationAgeBirthdate* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I have a different Permanent Address.* No YesMy Permanent Address is: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent / GuardianIf a dependant.Parent/Guardian (if patient is a dependant)RelationshipEmergency ContactEmergency Contact NameEmergency Contact PhoneReferring Health Care ProviderHealth Care Provider Phone #Family Physician*This field is hidden when viewing the formFamily Physician Phone #Family Physician Phone #Additional InformationHow did you hear about us?Type of Injury/ConditionOnset/Injury date MM slash DD slash YYYY Previous relevant injuryPlease List any previous Illnesses or SurgeriesCurrent MedicationsDo you have or have ever had any of the following conditions?(check all that apply) Allergies/Skin Sensitivities Autoimmune Deficiencies Cancer Circulation Problems Diabetes Easy Bruising/ Bleeding Fracture Kidney Disease Metal Implant Heart Problems Osteoporosis/ Osteopenia Sprain/ Strains Stroke Thyroid Problems Headaches Change in vision/hearing Dizziness/lightheadedness Weakness Fatigue Numbness/tingling Weight loss/gainWhat type of cancer?What type of diabetes?Where is your fracture located?Where is your sprain/strain located?Other (explain)Consent* I hereby state that the above information is accurate and true to the Print Name best of my knowledge.Date* MM slash DD slash YYYY Signature of Patient or Guardian*(if other than patient please list relationship)CancellationsWe respectfully ask that you provide a minimum of 24 hours’ notice if you must cancel an appointment. A fee of $70.00 will be charged for any late cancellation or no-show appointment.ConsentPatient Name* First Last Welcome to Kimberly Rau & Associates Inc. We want you to understand and consent to the services we provide to you, the costs involved, and know what we do with personal information we obtain about you. Please read the following information and if you have any questions, please ask. CONSENT FOR TREATMENT Our health care practitioners are trained professionals licensed by regulatory bodies for their specific profession to provide treatment for health related concerns. Assessment and treatment will include observation and physical examination and possibly casting and fitting of foot orthotics. The treatment services you undergo may be administered by the treating professional and by pedorthic students under the supervision of the treating professional. By signing this form, you agree to our treatment. CONSENT FOR THE COST OF OUR SERVICES By signing this form, you agree: ● to pay for all services when they are provided ● if you do not pay for a service at the time it is received, to pay interest on any outstanding balance at the rate of 2% per month and, on default of payment, to pay al costs of recovering the debt, including legal and/or agent costs ● to provide a minimum of 24 hours’ notice if you must cancel an appointment. A fee will be charged for any late cancellation or no-show appointment according to the type of appointment booked. Your appointment time is reserved exclusively for you and our professionals cannot use this time to see other patients.Initial*(above section read)CONSENT TO COLLECT AND DISCLOSE PERSONAL INFORMATION Kimberly Rau & Associates Inc. will collect some personal information about you (including without limitation, your name, age, contact information, health benefit information, occupational information, personal health information, medical history, etc.) in order to provide you with rehabilitation services and products. A copy of our Clinic Privacy Policy is available which contains additional information about the collection, use, disclosure, retention and accuracy of personal information, steps taken to protect the information, and your right to review your personal information. Please ask if you wish to read/review our Clinic Privacy Policy. By signing this form you agree that: ● Kimberly Rau & Associates Inc. may collect, use, and disclose personal information about you as set out in this form and in our Clinic Privacy Policy ● You understand how our Clinic Privacy Policy applies to you ● You have had an opportunity to ask any questions you have about our Clinic Privacy Policy and they have been answered to your satisfaction ● You understand there are some rare exceptions to the commitments in our Clinic Privacy Policy, as explained in the Policies and Procedures for Personal Information issued by the Government of Canada ● We may exchange (release and receive) your medical records with your attending physician, insurance company, legal representatives, employer, the Workers Safety Insurance Board and any other Health Care Professional relevant to your care I have read the Consent Form above and I agree to Kimberly Rau & Associates Inc. collecting, using, and disclosing personal information about me as set out above and in the Clinic Privacy Policy of Kimberly Rau & Associates Inc.Patient Signature*Date* MM slash DD slash YYYY Parent/Guardian SignatureDate MM slash DD slash YYYY Parent/Guardian Name (Print)Relationship
