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REFER A FRIEND | FAMILY

REFER A FRIEND / FAMILY

Do you have a family member or friend suffering with aches & pains. You could refer them to our services to improve your loved ones quality of life. Please fill out the form below and let them know that you have referred them to Goreway Physio or ask them to contact us. We appreciate your help.

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+1 (905) 612-8222
+1 (905) 612-8752
gorewayphysio@gmail.com
https://gorewayphysiotherapy.com/
7330 Goreway Drive, Unit 20 Mississauga, ON L4T 4J2

INITIAL INTAKE FORM

Welcome to Goreway Physiotherapy & Rehabilitation Centre! In order to serve you better, please take a moment to complete this form. If you require assistance, please see the receptionist. When finished, kindly return this form to the front desk.

Have you ever been a patient here before?

YesNo

If Yes, when?

How did you learn about us? (if referred, please name the referral)

Patient Information (please complete all of the fields below) :

Gender

MaleFemale

Case Information (please indicate the reason for your visit and complete all of the related information):

Automobile Accident

Have you already reported your injuries to the insurance company?

YesNo

Were you employed at the time of the accident?

YesNo

Do you have Extended Health Care benefits coverage?

YesNo

Work Injury

Slip & Fall

Sports Injury

Others

Patient Signature (please print your name, date and sign):

To the best of my knowledge, I certify that the information provided above is true and correct.

Please present the following documents:

Driver's LicenseHealth Card (OHIP)Police ReportInsurance Pink SlipExtended Health Benefits CardOthers
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Goreway Physiotherapy & Rehabilitation Centre is one of the most reliable clinics in Mississauga having experienced therapists to serve physiotherapy, massage therapy, shockwave therapy, acupuncture, and chiropractic care. Moreover, if you are looking to purchase custom orthotics, compression stocking and bracing products, we are a one-stop destination for you.

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