Active Recovery Clinic General E-Intake





General Information - Place cursor in space provided and type in information!




General Services Sought(*)

Invalid Input

Type:(*)

Invalid Input

Area needing treatment:(*)

Invalid Input

Name(*)

Invalid Input

Date of Birth(*)


Invalid Input

Email Address(*)

Invalid Input

Full Address (Street, City, Postal Code)(*)

Invalid Input

Main Phone Number(*)

Invalid Input

Emergency Contact Name(*)

Invalid Input

Emergency Contact Phone Number(*)

Invalid Input

Family Physician(*)

Invalid Input

Your Occupation

Invalid Input


Past-current Medical History Questions




Check for "YES"




















Invalid Input

If you selected "YES" to Allergies, please expand

Invalid Input

If you clicked "YES" for Cancer, please enter the type and location

Invalid Input

If you clicked "YES" for Surgery, please enter the type and date of the surgery

Invalid Input


Third Party Payer Information: (fill out as applicable below)


Note 1

For Motor Vehicle Insurer claims Extended Health funding information & Motor Vehicle Insurer information are required as per the Statutory Accident Benefit Schedule SABS Provincial Regulation. See appendix 1.

Note 2

For Work Place Injury Claims WSIB both Extended Health funding information & WSIB claim information are required to start treatment immediately and prior to WSIB providing Active Recovery with approved funding billing memo #. Complete during first visit.



Extended Health




Employer Name

Invalid Input

Employer Address

Invalid Input

Employer Phone Number

Invalid Input

Job Title

Invalid Input

Years Employed

Invalid Input

Name of Insurance Company

Invalid Input

Name of Policy Holder

Invalid Input

Policy Number

Invalid Input

ID

Invalid Input


Work Place Injury




WSIB Claim Number 123-45-678

Invalid Input

Date of Accident (DD/MM/YYYY)


Invalid Input

Work Status

Invalid Input

Has the WSIB FORM 6 been completed?

Invalid Input


MVA Information




Policy Number

Invalid Input

Claim Number

Invalid Input

Insurance Policy Owner (If not yourself)

Invalid Input

Accident Benefit Adjuster Name

Invalid Input

Phone Number

Invalid Input

Captcha(*)
Captcha

Invalid Input