This is a confidential intake form called a preliminary screening form.
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We are screening you to see if you suffered a serious spinal injury as the result of your motor vehicle accident.
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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.
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IT TAKES APPROXIMATELY 10 MINUTES TO COMPLETE THIS FORM
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:
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.
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.
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.
