CLIENT INTAKE FORM FOR BOOKED CLIENTS

Please do not Print this form, simply fill in the blanks and then select the clinic location you are booked into at the bottom and then click the "Send" button. It's just that easy!














    Date of Birth:







    *We would like to keep your medical team up to date on your progress. Do you authorize OKAPED to
    send a report back to your referring professional and your family physician?


    YesNo


    Please provide us with a brief description of your discomfort or concern:







    OKAPED Patient Privacy and Consent to Treatment

    Personal Information

    Protecting your privacy and personal information is an important part of OKAPED’s policies and
    procedures.

    We will use and disclose your information only for the following purposes:

    • To ensure the accuracy of information on file and to be able to contact you
    • To comply with professional, legal and regulatory requirements or as otherwise required by law
    • To provide health plan insurers information in order to process your claims and benefits
    • To confer with your health care provider or inform them about your treatment plan

    Consent to Treatment and Covid-19 Health Status

    I hereby give my consent to undergo assessment and treatment at OKAPED. Where appropriate, my
    treatment is not limited to, and may include visual observation of body alignment, testing of relevant
    range of motion of joints (including manual testing), palpation of affected region, relevant functional tests to effected region, observation and video analysis of my walking or specific movement pattern, limb measurement, and relevant strength testing of affected areas. Your clinician will discuss the specifics of your treatment including but not limited to foot orthotics, footwear and footwear modification as well as bracing recommendations, exercises and stretching routines.

    By indicating “YES” below and dating this consent form, you have agreed that you have given your
    informed consent to the collection, use and disclosure of information for the purposes identified in this form and you agree to be assessed and treated at OKAPED. In addition you acknowledge that you are currently not experiencing symptoms of Covid-19. PLEASE NOTE, the cost of a biomechanical assessment is $79.95 and is charged at the time of the biomechanical assessment unless prior written authorization to bill the agencies listed below has been provided. There is no fee for Bracing appointments.


    YesNo



    Please indicate below if this condition is related to an active claim.


    WorkSafeBC

    ICBC

    DVA/RCMP

    Ministry of Social Development

    FNHA

    I authorize OKAPED to send an assessment report(s) and treatment notes to agency indicated above:

    Yes
    No


    Which clinic do you want to send this form to?