Chiropractic Intake Form

I authorize MOVE Physiotherapy to use and disclose my medical information for purposes of treatment, payment and health care to the following:

I understand that I have the right to revoke this consent provided that I do so in writing, except to the extent that MOVE Physiotherapy has already disclosed the information based on this consent.

Cancellation/Late Policy

If you are unable to attend your scheduled appointment, we require 24 hours notice, for cancellations or rescheduling. If you fail to do so, a charge equal to 50% of the appointment in question, will be charged. If you do not show for an appointment, then you will owe for the full charge of that appointments . Cancelation charges can not be covered through Extended Health Care benefits, MVA/WCB Insurers or MSI. If calling outside of business hours, please leave a detailed message. If you arrive 15 minutes or more past your scheduled appointment time you may be asked to reschedule and have a cancellation charge applied to your account.

Payment Agreement

MSI does not cover any of MOVE’s services; therefore you, the patient, are responsible for payment of services rendered. Payment is due at the time of your appointment. Many patients have Extended Health Care (EHC) Benefits to offset the cost of our services. We direct bill most, if not all EHCs, the Worker’s Compensation Nova Scotia and Motor Vehicle Insurers. It is your responsibility to know the details of your own plan. If you are covered under more than one policy, please note that we will only bill the primary policy. Any fees above this amount are your responsibility. (MOVE Physiotherapy reserves the right to refuse direct billing to any insurance company).

Please Note: If your claim is refused or denied by Worker’s Compensation Board, your Motor Vehicle Insurer or your personal Healthcare Insurer, you are responsible for all payments for services rendered. These fees may include, but are not limited to the following: treatment fees, product fees and fees for any forms completed during treatment.