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BOOK APPOINTMENT (905) 230-6651

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Home
About
Physiotherapy Services
Conditions Treated
New Patients
Blog
Contact

BOOK NOW

Initial Intake Form

Welcome to Active Physiotherapy Brampton Inc.! In order to serve you better, please take a moment to complete this form.
If you require assistance, please see the receptionist. When finished, kindly return this form to the front desk.

Have you ever been a patient here before?

Yes

If Yes, when?

How did you learn about us? (if referred, please name the referral)

Patient Information (please complete all of the fields below)

Last Name

First Name

Intl.

Address

Street

City/Town

Province

Postal Code

Date of Birth (mm/dd/yyyy)

MM slash DD slash YYYY

Gender

Male

Female

Employer/Occupation

Name of Emergency Contact

Relationship

Name of Family Doctor

Family Doctor Tel.

Home Tel.

Work Tel.

Mobile

Emergency Contact Tel

Patient's Email

Case Information (please indicate the reason for your visit and complete all of the related information)

Automobile Accident

Date of Accident

MM slash DD slash YYYY

Name of Automobile Insurance Company

Have you already reported your injuries to the insurance company?

Yes

Were you employed at the time of the accident?

Yes

Do you have a legal representative?

Yes (please provide name)

Name

Do you have Extended Health Care benefits coverage?

Yes (please provide name of insurer)

Name of Insurer

Work Injury

Date of Accident

MM slash DD slash YYYY

Claim Number (if known)

Nurse Case Manager:

Tel

WSIB Adjudicator:

Tel.

Do you require treatment as a result of work related injury?

Yes

Other

Other Injury

Patient Signature (please print your name, sign, and date) To the best of my knowledge, I certify that the information provided above is true and correct.

Name of Patient

Date

MM slash DD slash YYYY

Signature of Patient

Hear From Our Patients

Discover how our compassionate care and personalized physiotherapy have helped real patients
reduce pain, restore mobility, and regain strength—so they can get back to living fully.

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