Motor Vehicle or Workplace Accident
Automobile Insurance Information
Coverage Details (if applicable)
The information requested below will assist us in treating you safely. Feel free to ask any questions about the information being requested. Please note that all information provided will be kept confidentially unless allowed or required by law. Your written permission will be required to release any information.
2. Do you presently have or ever had any of the following? Check all that apply:
Please read the following carefully and fully:
Palermo + Physiotherapy & Wellness Centre is a multidisciplinary health care provider where the practitioners work in conjunction to provide you, the patient, thorough care and treatment. All staff members are required to sign a confidentiality form with regards to your personal information and are trained in appropriate use and protection of your information.
All handling of your information is compliant with existing college guidelines and provincial and federal legislation. Our clinic uses your information to ensure you receive the best care.
I understand that payments for services at Palermo + Physiotherapy & Wellness Centre are my responsibility after every service is received. If my claim is to be submitted to an outside agency for payment, and for any reason the third party payer, such as insurance or employer denies and/or refuses to pay for the full amount I am billed, I am responsible for payment.
Cancellation of Appointment
Palermo + Physiotherapy & Wellness Centre requires a minimum of 24 hours notice
for any appointment cancellations. Should you give less than 24 hours notice, a $45.00 cancellation charge
may be charged. Your appointment time has been reserved specifically for you. Should you book an appointment and not to attend, you are responsible to pay for the entire cost of the appointment.