Active Recovery Clinic General E-Intake





General Information - Place cursor in space provided and type in information!




Name(*)

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Date of Birth(*)


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Email Address(*)

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Full Address (Street, City, Postal Code)(*)

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Main Phone Number(*)

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Emergency Contact Name(*)

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Emergency Contact Phone Number(*)

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Family Physician(*)

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General Services Sought(*)

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Your Occupation

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Third Party Payer Information: (fill out as applicable below)


Note 1

For Motor Vehicle Insurer claims Extended Health funding information & Motor Vehicle Insurer information are required as per the Statutory Accident Benefit Schedule SABS Provincial Regulation. See appendix 1.

Note 2

For Work Place Injury Claims WSIB both Extended Health funding information & WSIB claim information are required to start treatment immediately and prior to WSIB providing Active Recovery with approved funding billing memo #. Complete during first visit.



Employer Extended Health




Name of Insurance Company

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Name of Policy Holder

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Policy Number

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ID

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Work Place Injury




WSIB Claim Number 123-45-678

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Date of Accident (DD/MM/YYYY)


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Body Part Approved For Claim

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Name of WSIB Case Manager

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Name of WSIB Nurse

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Work Status

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Past-current Medical History Questions




Check for "YES"






















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If you clicked "YES" for Cancer, please enter the type

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If you clicked "YES" for Surgery, please enter the type and date of the surgery

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Current Physical Problem




Diagnosis Provided By Doctor or Specialist?

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Area of Injury/Pain Location

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Your Concerns

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Appendix 1: Motor Vehicle Insurance Information




Policy Number

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Claim Number

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Insurance Policy Owner (If not yourself)

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Accident Benefit Adjuster Name

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Phone Number

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