Alpha Health Services Intake Form Date* Name* First Last Contact InformationEmail Home Phone*Work / Cell Phone Personal InformationOccupation*Date of Birth* How Did You Hear About Alpha Health Services?Medical InformationDoctor's NameDoctor PhoneEmergency Contact Name*Emergency Contact Phone Injury InformationIs this injury the result of an accident at work and therefore being claimed from the Workers Compensation Board?*YesNoIs this injury caused by a car accident?*YesNo PermissionI hereby give authorization for Alpha Health Services to collect my personal/health/medical information and I authorize all information to be communicated to the following parties: MVA Insurance Co. Employer Laboratories/Radiology offices Family Physician Private Insurance Carrier I do not authorize the release of any of my personal information Alpha Health Services Policies:Please provide 24 hours notice of cancellation for your appointment. A fee of $30 will be charged to your account if you do not show up for your appointment or if you choose to cancel within 24 hours of your appointment time. * I agree Late arrivals will be seen for the remainder of their appointment time only. It is our goal to stay on schedule to the best of our abilities and so we must get to the next patient on time. * I agree Payment is due in full at the end of each treatment session. Payments will be accepted by cash, debit, or credit card, and a receipt will be provided for reimbursement by your insurance company after each visit. * I agree * Please note that each patient's insurance agreement is an agreement between themselves and the insurance company directly. In the event that any insurance company or 3rd coverage provider does not completely reimburse or even rejects any health service claim provided at Alpha Health Services, the patient is still responsible for all fees.If your visit is as a result of a motor vehicle accident please provide all necessary information to our staff before your appointment. This includes your private insurance information (if applicable), adjuster contact information, and claim number. * I agree You're Finished!Thank-you for taking the time to fill out this form. Upon arrival, you will be presented with a printed copy of this form and will be asked to sign to confirm that all of the information you have entered is correct.Please click Submit when you're ready to send the form.