Patient Information for Booked Patients

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*

Occupation (Helps define walking and standing hours)

Your Home City

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?*

*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?*

Yes

Date Of Authorization*

2. 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?*

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.*

Yes.

Yes, I am the Parent or Legal Guradian of the Client.

Name of person giving consent.*

Date of 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 Active Claim Number:

3rd Party Agency selection if you have authorization for us to bill them.
Worksafe BC
ICBC
FNHA
DVA
RCMP
Min. of Social Development

3rd Party related: I authorize OKAPED to send an assessment report(s) and treatment notes to agency indicated above:

Yes

No

3rd Party Communications Authorization Date
MM slash DD slash YYYY

5. Select Your Clinic Location, then CLICK "Submit Form". Ensure you see the Successful message. Errors will be highlighted in RED. Please fix and Click "Submit Form" again for success!*

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

Client Intake
Form

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

Assessment Appointment Info