REFERRAL NOT REQUIRED
20027 Lessard Rd, Edmonton | MON - FRI 9-7pm SAT 9-4pm SUN & STAT Closed
#416 - 101 Jennifer Heil Way, Spruce Grove | MON - FRI 9-7pm SAT 9-4pm SUN & STAT Closed
Book Appointment
Book a Session
Evolution Physiotherapy Evolution Physiotherapy

Patient Forms

Patient Forms page image
Resources

Patient Forms

A patient completing intake information on a tablet with help from an Evolution Physiotherapy team member
Patient Forms

Complete Your Intake Form Before Your Visit

Save time before your appointment by completing your patient intake form online. Have your contact, health and insurance information available, and provide as much relevant information as you can about the reason for your visit.

After submission, the completed form is sent to Evolution and a PDF copy is emailed to the address you provide.

Before Your Visit

Have questions before completing your form?

If you’re unsure what information you need or have a question about your upcoming appointment, Evolution can help.

Contact Evolution
Evolution Physiotherapy

Patient Intake Form

Please complete the information below before submitting your form.

Your completed form will be emailed to Evolution Physiotherapy and a PDF copy will be sent to the email address you provide.

Patient Information

Tell us who you are and how we can reach you.

Sex

Appointment Location

Choose the clinic connected with your appointment.

Preferred Clinic / Appointment Location

Reason for Visit

Include the area of concern, how long it has been bothering you, and anything relevant to your visit.0 / 180 words
Include relevant medical history, previous treatment or current medications you feel your practitioner should know about.0 / 180 words

Work-Related Incident

Is this injury related to work?

Motor Vehicle Accident

Is this injury related to a motor vehicle accident?

Direct Billing Authorization

Please note that Evolution Physiotherapy is able to direct bill to most extended health benefit plans. It is the responsibility of the patient to know their coverage and limits.

I authorize Evolution Physiotherapy to direct bill the extended health benefits listed on my behalf. I hereby accept financial responsibility for all charges incurred that are not covered by direct billing to the clinic. Assignment will remain in effect until revoked in writing to the clinic.

Treatment Consent

I hereby consent to treatment and care provided by therapist(s) at Evolution Physiotherapy. Your therapist will determine the treatment plan that will work best for your condition. Treatments may include manual therapy, cupping, needling, ultrasound, shockwave or other therapies recommended by your therapist.

Please be aware that some treatments may cause bleeding, bruising and/or a temporary increase in soreness. If you have any concerns post-treatment please contact the clinic or speak with your therapist.

Signature

Sign above using your mouse, finger or stylus.