← Return to forms & documents New Patient Registration Form Patient Information Name * First Name Last Name Birth Date * MM DD YYYY Sex * Female Male Prefer not to answer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Primary (###) ### #### Phone Secondary (###) ### #### Email * Height Please note unit (Ft, cm, etc.) Weight Please note unit (Lbs, Kgs, etc.) Shoe Size Please note unit (cm, US, EU, etc.) Family Doctor Information Name, Phone number, Other contact information, etc. Why did you choose us? / Referred to by: Convenient Location Flyer Family Friend Doctor Online result Other INSURANCE INFORMATION In order to help you with insurance claims, or direct billing, we need the following information. Are you covered by insurance? * Yes No If yes, what is your Primary Insurance Company? If no, skip to the next section of the form (IN CASE OF EMERGENCY). Occupation Employer Who is the policy holder of this insurance? Self Spouse Parent Child Other Member's name If the policy holder is yourself, feel free to skip to Group No. First Name Last Name Member's Birth Date If the policy holder is yourself, feel free to skip to Group No. MM DD YYYY Group/Policy No. What is this? Member ID No. Do you have a secondary insurance plan you'd also like to use with us? Please list the same required information as above IN CASE OF EMERGENCY Emergency Contact First Name Last Name Their Phone Number (###) ### #### Relationship to you AGREEMENT By agreeing, you confirm that: * The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the clinic. I understand that I am financially responsible for any balance. I authorize Active Rehab Centre or insurance company to release any information required to process my claims. I also authorize Active Rehab Centre to release information regarding my medical condition to my family physician. Agree Disagree Thank you!We’ve received your form, see you at your appointment!For your first visit you will also need to fill out the appropriate intake form for the service you are visiting us for.
