Client Intake Form - Okaped Pedorthists Clinic Kelowna

Today's Date:

Occupation (Helps define walking and standing hours)

Contact**

Email*

Referred By: First and Last Name

Family Doctor: First and Last Name

Height**

Weight**

Shoe Size**

Date of birth**

Month*

Year*

Age*

Leisure / Athletic Activities

How did you hear about OKAPED?*

Date Of Authorization*

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

Location of discomfort:*

When does this occur?*

How long have you experienced this?*

What have you tried so far?*

Has it helped?*

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

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. PLEASE NOTE, the cost of a biomechanical assessment is $89.95 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.

Date Of Consent*
MM slash DD slash YYYY

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

Active Claim Number:

Authorization Date for 3rd Party Communications
MM slash DD slash YYYY

Which clinic do you want to send this form to?*

Email
This field is for validation purposes and should be left unchanged.

Client Intake
Form

Booked Assessment appointment form.

Assessment Appointment Info

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

OKAPED Patient Privacy and Consent to Treatment

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