Bonavista Physical Therapy
739 Lake Bonavista Dr. SE, Calgary, Alberta Tel: 403 278-0705 | www.bonavistaphysio.ca Please print clearly. ! Email Address: ______________________________________________ Name: _____________________________________________________ (last)
Birth Date: __________________________________________________ (month)
Alberta Health Card #: ____________________-_____________________ Family Physician: _____________________________________________ (first initial & surname)
Your Address: ________________________________________________ City/Town: ___________________________________________________ Postal Code: ________________ Province: ____________ Home Phone: (_______)_________ - _________________ Work Phone: (_______)_________ - _________________ Cell Phone:
(_______)_________ - _________________
Incident Date: _________________________________________________
General Information: Have you received physiotherapy treatment in the past year? ____________ If so, where?!________________________________________________
Is your injury due to a motor vehicle accident?!________________________
Is your injury due to an accident at work?!____________________________
Were you referred to Bonavista Physical Therapy? !____________________ If yes, by whom? !____________________________________________ If no, how did you hear of us? !__________________________________
What are your goals and expectations of Physical therapy?!______________ _____________________________________________________________
Fees for physiotherapy are as follows: 1. Private:! $95.00 First visit (assessment & treatment) !
$65.00 Subsequent treatments (Seniors: $55.00)
2. MVA (for accidents not covered under protocol) !
$150.00 First visit (assessment & treatment)
$88.00 Subsequent treatments
Based on your injury and treatment type, please choose the correct form below, print it, fill it in and bring it with you to your appointmen...