Adult Functional Health Intake Form

NEW CLIENT FORM
Please fill in all of the information to the best of our ability.

* This information will be kept strictly confidential. Your personal information is collected for the purpose of providing health care and for administrative purposes. It will not be disclosed for other purposes without your consent other than for reasons stated in the laws.
Demographic Info
Full Name *

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Age
Birth Date *

Month Day Year
I identify my gender as… *

Man Woman Trans
My preferred pronouns are:
Mobile Number

Area Code Phone Number
Home Number

Area Code Phone Number
Work Number

Area Code Phone Number
I wish to receive appointment reminders by:

Email Text Message Both
My cell phone carrier/provider I wish to receive reminder text messages is:
CareCard / MSP #
I have premium assistance MSP (low income, eligible for $23 towards some visits)

Yes No
I have extended health coverage through:
The Plan Holder is (i.e. personal that owns this plan, either you, your spouse, mother, etc.):
My policy or member ID # is:
My plan # is:
In case of an emergency I want you to contact

First Name Last Name
Contacts Phone number

Area Code Phone Number
Relationship
Marital Status

Single Common-Law Married
Spouse or Partner's Name

First Name Last Name
Number of Children
Your Occupation:
Number of hours I work per week:
I discovered Empower Health Clinic by: *

Internet Search (Google) Yelp! Twitter Facebook LinkedIn Yellow Pages Students "I Have a Plan" Sandwich Board or Walked by Flyer or Brochure Magazine or Newspaper Advertisement or Promotion Another Business Other Healthcare Provider
If you found us through a google search which words did you use?
Appointments & Fees
Missed Appointments

We require at least 24 hours notice if you wish to cancel or re-schedule an appointment or you will be charged for the time set aside and, in the case of a scheduled treatment, the cost of non-reusable products prepared for you. Notice of cancellation or rescheduling must be given during regular clinic hours or prior to regular clinic hours covering this 24 hour period.

You can find the fee schedule here: http://www.empowerhealth.ca/appointments/fees-and-prices/
Should be Empty:

Demographic Info

Appointments & Fees