Evolve Brampton Online Intake Form
    Thank you for filling out our convenient online intake form. This will help us serve you faster upon your arrival. This only takes a moment.

    Full Name *
    Sex MaleFemale
    Date of Birth*
    Phone (Mobile)
    Emergency Contact & Phone*
    I consent to receiving email appointment reminders & clinic promotions*Yes, I agree
    We will never send spam or share your email with third parties
    Family Doctor Name & Address
    Date of last appointment or physical
    What do you do mostly?
    How did you hear about our clinic?
    Please describe your present complaint
    Please check any of the following which you are currently suffering or have suffered in the past. You can check multiple boxes.

    CancerBreast Lump/PainChronic CoughDifficulty BreathingEaracheKidney InfectionSpeech ProblemsBleeding DisorderVaricose VeinsArthritisDiabetesItchingAllergiesNausea / VomitingHemorrhoidsUrination Problems

    Heart or Blood DiseaseSevere Menstrual CrampsSpitting Up BloodDouble / Blurred VisionAsthamaSinus ProblemsDifficulty SwallowingHigh Blood PressureHardening of ArteriesLoss of StrengthDisc herniationBruise EasilyPoor AppetitePain Over StomachJaundiceBlood in Urine or Stool
    High CholeseterolHot FlashesChest PainDeafnessFrequent ColdsEnlarged GlandsSeizures / EpilepsyStrokeSwelling of AnklesUlcerRashesBoilsIndigestionConstipationGall Bladder Problems
    Have you had a similar service before?
    If so, when was your last visit?
    Was this an injury that occurred at work?
    If so, what is your WSIB Claim Number, if applicable?
    Is this an injury as a result of a car accident?
    If so, is there a pending claim?
    Do you currently smoke?
    How often do you exercise?
    If you exercise, what activity is it?
    Any prior surgery?
    Any prior hospitalizations?
    Do you currently take any prescription or over the counter medications or vitamins/nutritional supplements? If so, please specify:
    What would you like to achieve by attending our clinic?
    Do you have private insurance? If so, what is your policy number?
    Who is your carrier?
    What is your insurance contact phone number?
    What is your maximum cover charge ($) for Chiropractic
    What is your maximum cover charge ($) for Chiropodist
    What is your maximum cover charge ($) for Naturopath
    What is your maximum cover charge ($) for Acupuncture
    What is your maximum cover charge ($) for Massage Therapy
    What is your maximum cover charge ($) for Physiotherapy
    What is your maximum cover charge ($) for Custom Orthotic / Shoe
    What is your maximum cover charge ($) for Custom Orthotic / Shoe
    What is your maximum cover charge ($) for Dieticians
    What is your maximum cover charge ($) for Medical Device
    What is your maximum cover charge ($) for Compression Stockings
    What is your maximum cover charge ($) for Other Health Care Spending Amounts
    Patient Agreement*

    Yes, I understand and authorize
    I understand that that any missed appointments that are not cancelled within 24 hours of the appointment time will be charged as a regular visit.I hereby authorize Evolve Brampton with my prior knowledge, to release to or obtain any health information from my other healthcare providers as may be required for: • Providing health care; • Advising you of treatment options • Establishing and maintaining contact with you regarding appointments invoicing and follow-up care; • Sending you pertinent information and mailings; • Facilitating your insurance claims; • Allowing potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale; • Complying with the legal and regulatory requirements of the Drugless Practitioners Act. I have read and understand the Evolve Brampton privacy policy and cancellation policy. I am aware that if insurance claims are being submitted on my behalf that I am responsible for any outstanding balance not covered by my insurance policy