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Confidential Medical History
ACTIVE THERAPY INTAKE FORM
FEE for review of your medical history + tele-medicine consultation with Dr. Rice $122
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So you want to be an ACTIVE THERAPY patient with Better Call Doc?

Great! We want to help you.

This form is for you if you are skipping with any pain therapy altogether & are moving straight to active therapy rehabilitation.

You feel you are ready to use exercise &

movement therapy to help manage your condition.

Let's start with your medical history,

then you will consult directly with Dr. Rice.

IT TAKES APPROXIMATELY 6 MINUTES TO COMPLETE THIS SECTION

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

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.

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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General
Gastro-intestinal
Cardio-vascular
Skin
Genito-urinary
For women only
Respiratory
Have you eve been diagnosed with:
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I understand that Dr. Michel Rice is formally my doctor of chiropractic who I am consulting with on the personal medical subject matter described in this form.

I understand that Dr. Michel Rice clinically directs the active therapy program.

 

Dr. Rice works with my fitness practitioner for both program supervision and clinical re-evaluations. Fees for medical review + initial consult [$122] & re-evaluations [$62] apply.

The clinic does NOT extend direct insurance billing. Rather, once a receipt is provided the patient (you) may submit a receipt for direct payment from the insurer using a DC licence 2225 [doctor of chiropractic - Province of Ontario]