In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

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Family History

Habits

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Contact

Get Directions
 
Southside Health and Rehabilitation
33 Godfrey Dr
Copper Cliff, ON P0M 1N0
Get Directions
  • Phone: 705-522-7678
  • Fax: 705-522-7802
  • Email Us

Office Hours

DayMorningAfternoon
Monday8:00 - 12:00p2:00 - 5:00
TuesdayEvaluations2:00 - 6:00
Wednesday8:00 - 12:00p2:00 - 5:00
ThursdayEvaluations2:00 - 6:00
Friday8:00 - 12:00pEvaluations
SaturdayBy AppointmentClosed
SundayClosedClosed

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