signature test - Richmond Hill Physiotherapy, Sports, Massage RMT, Pain Relief, Injuries & Rehabilitation

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For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic

Conscent Form

Name*
Email (if you want a copy)
Date of Birth *
Which Therapist Are You Seeing Today?*
Which therapist will you be attending? Devorah Eisenman BHK, RMTSusan Patterson, RMTTien Dao, RMTOther
*
How did find out about this event?
Client Name/Guardian:

Declaration:
I have answered all the above questions honestly and truthfully
Signature

* Required