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Booking Request Form

Have you attended our clinic in the last 3 months for the service you are requesting and for the same area of concern?*

Yes

Which of the following applies to you?*

Services:

Reason for your visit:*

Date:

Time slot:

Provide your contact details:

Provide your contact details:

* Indicates a required field.

First Name:*

Last Name:*

Phone:*

Email:*

Personal information note

Your personal information will remain private and will not be shared with anyone outside of Prime Health Physiotherapy.

AUTHORIZATION FOR SUBMISSION & DIRECT PAYMENT

AUTHORIZATION FOR SUBMISSION & DIRECT PAYMENT

Please fill out form ONLY if we bill directly to your insurance company. List can be found in FAQ. Please put N/A if not applicable.

Insurance Coverage:*

If "No" or "will submit myself" please skip to the next section.

Insurance Company:*

Insured Member First & Last Name:*

Insured Member Date of Birth:

Extended Health Care PLAN/CONTRACT Number:

Extended Health Care Member I.D/CERTIFICATE Number:

opt-in

By submitting this form, I hereby authorize Prime Health Physiotherapy Conditioning to submit to my health care benefits on my behalf, and assign the payment for my health care benefits, as per the enclosed invoice, directly to Prime Health Physiotherapy As an EHC client, should any submitted claims deem unplayable, I agree that I will be held responsible to pay any outstanding balance for services rendered with the Corporation of prime health physiotherapy Please be advised the authorization form for submission & direct payment will be valid until discharge and all accounts have been cleared. I have read and understand.

Thank you kindly for your cooperation with this matter.

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