CLIENT INTAKE FORM FOR BOOKED CLIENTS

Only fill this in if you have been directed to do so by our staff.














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 collect, use, disclose, retain and dispose of your personal information in compliance with federal and provincial privacy legislation and our applicable Canadian college regulations.

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

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.


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?