General Intake Form

Name
First Last
Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Date of Birth
MM slash DD slash YYYY
Emergency Contact Name & Relation To You
Emergency Contact Phone
Who referred you to Pure Pelvic Health?
Who is your family physician?
First Last
Even if you can't remember how to spell your doctor's name please take your best guess. If you do not have a family doctor leave blank.
Should Pure Pelvic Health send a copy of our initial assessment report to your family doctor?
- Please send a copy of Pure Pelvic Health initial assessment to my family doctor
- Please do not send a copy of Pure Pelvic Health initial assessment to my family doctor
Health History Information
- Heart Disease
- High or Low Blood Pressure
- Diabetes
- Cancer
- Endometriosis
- Fainting or Dizziness
- Headaches / Migranes
- Osteoporosis
- IBS
Are you currently under medical care for any of the following conditions or do you have a history of the following conditions? Select all that apply.
Cancellation Policy
- I have read the above cancellation policy and acknowledge my responsibility to provide a minimum of 24 hours notice to cancel my appointment with Pure Pelvic Health
While we understand that unexpected situations arise that may require a client to cancel an appointment, please understand that we have saved this block of time just for you. It is not easy to fill this empty appointment time at the last minute. Therefore, please be advised that Pure Pelvic Health requires a minimum of 24 hours notice to cancel and appointment. Last minute cancellations or "no shows" will be billed directly to the client at a rate of $50.00 per missed appointment.
Payment of Account Contract
- I have read and understand Pure Pelvic Health's Payment of Account Contract
The client of Pure Pelvic Health accepts final responsibility for paying for all goods and services provided at Pure Pelvic Health's prevailing and published rates. Please review signs posted in our waiting room for current rates. If you have any questions please do not hesitate to ask any Pure Pelvic Health staff member. Your extended health plan is a contract between you and the insurance company, not between the company and Pure Pelvic Health. As the patient, you alone authorize your Pure Pelvic Health therapist to treat you. As such, you are solely responsible for the payment of fees including those that are not covered by your extended health insurance.

Call Now! (905) 218-6556

Call Now! (905) 218-6556