Intake Form

If you are interested in booking an assessment with Lynne Brochu, please complete the Intake Form below as it is required to receive an initial assessment spot.

Remember WCB and SGI sponsored clients are not seen at this clinic.

You will be contacted upon us receiving the form to book your initial assessment. If you do not receive a phone call within one full business day of submitting your form, contact us!

IMPORTANT: Please note:

There is no method to save your information, so complete the form in one sitting. This should only take 3 to 5 minutes to complete. Please be reasonably thorough so your initial assessment has adequate hands-on treatment time!

At the end, there may be a security box you must fill in. 

If you click ‘send’ and you do NOT see a checkmark with the statement “The form was successfully sent”, then we did not receive it. We will only receive the form if you see this confirmation statement.

The information asked of you in the forms is required for:

1) Your safety—Situations including, but not limited to, previous injuries, previous surgeries, and current health issues need to be communicated so that your assessment is tailored appropriately to you. You are required to disclose any and all health issues so safe methods are utilized for you.

2) To complete a proper assessment—The bylaws placed on physical therapists by their licensing body requires a thorough subjective history discussing things including, but not limited to, your medical history, current concern, and previous management. The chart must also contain demographic information including, but not limited to, your name, address, gender, date of birth, and occupation.

3) For communication to your referral source and/or General Practitioner—Your given name, health card number, and date of birth ensure that any information sent to other professionals identifies you properly.

4) For communication with you—Your address, phone number, and other methods as to how to reach you as well as your emergency contact information are required in case of emergency, need to change appointments, or other unforeseen circumstances.

Intake Questionnaire

*Please bring a copy of your referral (if you have one) and copies of any related investigative reports with you *
I currently have, or in the past had, the following health issues:
Please list all PRESCRIBED medications you are taking, and the purpose of each.
*Please bring a copy of your referral (if you have one) and copies of any related investigative reports with you *
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