Thank you for choosing Wilson Health Services for your healthcare needs. We are honoured you have chosen us to fullfill the important role in caring for you and your family.
Our clinic requires registration for all our new patients. This allows our practitioners to review your health information thus decreasing your wait time when you arrive for your visit.
Please remember that all extended health services are not covered by OHIP and payment in full is requiered at the time of treatment. If devices are made to aid in the management of a problem the patient is responsible for the payment at the end of the treatment. In the case of custom foot orthotics, a deposit is requiered upon casting and is due upon fitting.
We will gladly make adjustments to custom foot orthotics during the initial 3 months of wear to ensure devices are achieving the intended functions. There are no refunds on custom devices.
We requiere 24 hour notice to change or cancel a scheduled appointment. 100% of the fees will be due for no show or late notice appointment cancellations/changes.
Cash, Cheque, Debit, Visa and Mastercard are acceptable forms of payment.
Select options below indicating age at diagnosis and other relevant details.
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?
How do you want us to handle your problem/What are your long term expectations from your practitioner?
Please read the following carefully before signing.
We would like your informed consent. This means that we want you to understand the services we hope to provide to you & the cost involved, and what we do with personal information we obtain about you/ if you have any questions, please ask.
Physicians, Chiropractors, Osteopaths, and Physiotherapists are required to advise patients with neck problems of the following: There have been very rare incidents of injury to the vertebral artery during the course of treatment. This has caused strokes or stroke-like occurrences, which are usually temporary in nature. The chances of this happening are less than one in ten million. Tests, with or without x-rays, have been performed on you to minimize this risk to yourself. Chiropractic is considered to be one of the safest and most effective forms of therapy for neck conditions and other conditions.
· I understand all accounts are payable when service is rendered.
- Consent to all-encompassing chiropractic treatments knowing the Doctor(s) will discuss ahead of time with me. (Example: Orthotics, change of techniques, etc.)
- Consent to seeing another Wilson Health Services Doctor if/when needed. (Example: time restrictions, scheduling, acute condition needing help or when my primary Doctor is away, etc.)
- I understand that to provide me with the health goods and services, Wilson Health Services will collect some personal information about me. (e.g. home telephone number, address, etc.)
The privacy and protection of your personal information has always been an important part of our office. We are committed to collecting, using, and disclosing your personal information responsibly. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. In this office, Dr. Jason Wilson acts as the privacy information officer. Along with this consent form, we have outlined what our office is doing to ensure that:
- Only necessary information is collected about you
- We only share your information with your consent
- Storage, retention, and destruction of your personal information complies with existing legislation, and privacy protection protocols
- Our privacy protocols comply with privacy legislation, standards of the regulatory body, the college of chiropractors of Ontario, and the law.
- In the case of a missed appointment, our office has the right to call the phone number provided.
By signing the consent section of this patient consent form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality care.
* Please read and agree to the terms
Today's Date: 19 May 2019