Client Intake

Patient info form. Fill in only if you already have an appointment.

Assessment Appointment Info

"*" indicates required fields

1. Personal info

2. Fill in your problem or Injury description

3.Consent to assess and treat are required in this section.

4. This section is for 3rd Party Billing, skip if not applicable

5. Select which clinic you are booked into and are sending this form to.

6. Click on Submit Form. Ensure you see the "Successful Sent" message. Errors will be highlighted in RED. Please fix and Click "Submit Form" again for success!

1. Name*
Your Home City
*We would like to keep your medical team up to date. Do you authorize OKAPED to send a report back to your referring professional and your family physician?*
MM slash DD slash YYYY

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

3. 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.

I am 19 yrs or older and give informed consent.*
MM slash DD slash YYYY

4. 3rd Party Claim please fill in this section if you have an ACTIVE claim. If you do not simply skip to Section 5. Location.

3rd Party Agency selection if you have authorization for us to bill them.
3rd Party related: I authorize OKAPED to send an assessment report(s) and treatment notes to agency indicated above:
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.