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M Y  M E D I C A L   H I S T O R Y
MOTOR VEHICLE ACCIDENT CASE

01

CONFIDENTIAL
MEDICAL HISTORY


FILL-IN BELOW

02

PRESS SEND

GOES DIRECTLY TO DR RICE'S PATIENT INBOX

03

DR RICE RESPONDS

FIRSTLY
ACKNOWLEDGES RECEIPT

THEN
SETS UP A TELEPHONE CONSULT

04

YOU & THE DOCTR

TOGETHER
YOU WILL DECIDE WHAT THE NEXT STEP SHOULD BE FOR YOUR EXAMINATION, PAIN THERAPY OR REHABILITATION

Confidential    Screening    Examination
Specialty End-Range Stress Test X-ray Screen

In collaboration with the Ontario Research Medical Group,
[a sub-division of Better Call Doc Inc.]

This is a confidential intake form called a preliminary screening form.

We are screening you to see if you suffered a serious spinal injury as the result of your motor vehicle accident.

If the doctor thinks you may have a ligament instability in your neck or lower back,

we will proceed with an examination followed by a specialty x-rays.

IT TAKES APPROXIMATELY 10 MINUTES TO COMPLETE THIS FORM

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IF YOU PREFER TO FILL IN A PAPER FORM WE CAN DO THIS AT THE CLINIC OR WE CAN SEND YOU A FORM YOU CAN PRINT TO FILL-OUT.

ALTHOUGH WE ARE A PAPERLESS CLINIC WE WILL WILL SCAN YOUR DOCUMENT & SECURELY KEEP THEM IN OUR SECURE PATIENT SERVER.

TO REQUEST A MEDICAL HISTORY BY TELEPHONE PLEASE CALL OR EMAIL YOUR REQUEST:

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ATTENTION

THIS FORM DOES NOT SAVE A YOU COMPLETE IT. 

PLEASE BE PREPARED TO FINISH COMPLETING IT IN ITS ENTIRETY & THEN MAKE SURE YOU PRESS SEND.

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Date of Accident

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S C R E E N I N G    Q U E S T I O N S P E R T A I N I N G   T O   Y O U R   A C C I D E N T
Please check below ONLY if the answer to the question is YES
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General
Gastro-intestinal
Cardio-vascular
Genito-urinary
Skin
Respiratory
For women only
Have you eve been diagnosed with:

Upload any medical record you think we may want to review like written medical report, x-ray, MRI, CT Scan, ultrasound, blood work / urinalysis. You can always just bring the documents with you when you visit the clinic.

Upload your medical x-ray/MRI/CT reports

Thanks for submitting. The doctor will review your records. Your medical information complies with the provincial information privacy act using web server protection logistics & programming as well as in-clinic college regulations.