LightSpeed Physiotherapy - Serving Mississauga and Oakville 

                                                                   

 

 

 

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If you wish to save ten minutes when you first visit us, please fill out the patient Intake Form Below.

You may print the form below and fax it to us at (905) 823-2933 or you may bring the completed form with you when you first visit us.

Patient Intake Form

Name:

 

Date of Birth (mm/dd/yy):

 

Street Address:

 

City:

 

Province:

 

Postal Code:

 

Home Phone #:

 

Alternate Phone #:

 

Email:

 

Occupation: 

 

Employer:

 

Family Physician:

 

Phone #:

 
                                 

 Would you like us to send progress reports to your Family Physician?    q  Yes     q  No

 

Present Complaint (e.g. low back pain, carpal tunnel):

 

Date of Onset (please estimate if unsure):

 

 Health Questions

Are you pregnant?                                q  Yes     q  No     q Not Applicable

Do you have sensitivity to light? q  Yes     q  No

In your immediate family, is there a history of:

Heart Disease               q  Yes     q  No

Arthritis                        q  Yes     q  No

Cancer                         q  Yes     q  No

Diabetes                       q  Yes     q  No

Have you seen any physicians for this condition?                        q  Yes     q  No

          If yes, please specify:

 

Have you undergone any treatments for this condition?  q  Yes     q  No

          If yes, please specify:

 

Are you taking any medications?                                               q  Yes     q  No

          If yes, please specify:

 

 Referral Method:

 How did you hear about us? (Please check all that apply): 

q    Internet:

 

q    Newspaper:

 

q    Magazine:

 

q    LightSpeed Patient:

 

q    Other:

 

 

Information Request Form

Select the items that apply, and then let us know how to contact you.

Please have a therapist contact me to discuss my condition.
Please contact me by phone
Please contact me by e-mail

Name

Condition        i.e. arthritis

Any additional comments you may have regarding your condition

Address

E-mail

Phone

Home           

Contact Information                                                               Clinic Hours

Telephone: 905-823-2226                                                                         Monday, Wednesday & Friday 9 am to 6 pm
FAX:           905-823-2933                                                                         Tuesday & Thursday 11 am to 7 pm
                                                                                                              Saturday 9 am to 12 pm
Location:  Sheridan Centre, 2225 Erin Mills Parkway, Mississauga, ON L5K 1T9
         One block north of the QEW on Erin Mills Parkway
         We are located in the lower level of the mall, by the library
 
E-mail info@lightspeedphysio.com
Copyright © 2008 LightSpeed Physiotherapy Inc.
Last modified: 06/16/08