Appointment Request for Physiotherapy
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1. Let's start by getting to know you a little better.
First Name:
*
Last Name:
*
Gender:
*
Male
Female
Other
Date of Birth (DD/MM/YYYY):
*
Date Format: DD slash MM slash YYYY
2. Are you looking to be treated because of an injury?
Do you have an injury?
*
Yes
No
If yes, please give us a bit more information on your injury.
3. Is your pain chronic?
Yes
No
4. Do you need treatment following a car accident or an accident in the workplace?
Yes
No
Please note, we do not treat any injuries pertaining to car accidents involving the SAAQ or workplace accidents involving the CNESST.
5. When are you available for an appointment?
Potential Appointment Date (DD/MM/YYYY):
*
Date Format: DD dash MM dash YYYY
8. How can we reach you?
Email Address:
*
Phone Number:
*
Preference:
*
Email
Phone
Text
