About Us
Our Team
Services
For Patients
Funding
Contact
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About Us
What is a Certified Orthotist?
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Who We Serve
Orthotic Devices
Serial Casting
Dynamic Movement Orthosis (DMO)
Innovative Solutions
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Facilities
Useful Resources
Pattern Choices
Back
Locations
Request for Appointment
About Us
About Us
What is a Certified Orthotist?
Our Team
Services
Who We Serve
Orthotic Devices
Serial Casting
Dynamic Movement Orthosis (DMO)
Innovative Solutions
For Patients
Facilities
Useful Resources
Pattern Choices
Funding
Contact
Locations
Request for Appointment
Certified specialists in custom orthoses, foot orthotics and orthopaedic bracing. Serving Toronto, Scarborough, Markham Richmond Hill, Aurora, Newmarket. With locations in Markham and Newmarket
Patient Information Form
Name
*
As appears on Health Card
First Name
Last Name
Preferred Pronouns
Gender
*
As appears on Health Card
Female
Male
Prefer Not To Answer
Date of Birth
*
MM
DD
YYYY
Health Card Number
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Diagnosis
*
Allergies
Name of Primary Caregiver
If different from above
First Name
Last Name
Relationship to Patient
Email
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Referred By
Family Physician
First Name
Last Name
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Paediatrician/Specialist
First Name
Last Name
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Therapist
First Name
Last Name
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Has the patient previously had any orthotic device(s) funded through the Assistive Devices Program (ADP)?
*
Yes
No
If yes, please indicate what type of device(s) were received and the date(s) they were received
Is the patient receiving any social assistance benefits?
*
Yes
No
If yes, please indicate which benefits the patient is receiving
Please remember to bring your most recent statement to your appointment
Ontario Works Program (OW)
Ontario Disability Support Program (ODSP)
Assistance to Children with Severe Disabilities (ACSD)
Does the patient have any coverage through any private, work or third-party insurer?
*
PLEASE NOTE: We are unable to bill directly to insurance companies
Yes
No
If yes, please provide the name of your insurer
I give permission for any professional from OrthoProActive Consultants Inc. to discuss my medical history/condition/follow-up with my doctors, therapists or any other medical health professional. I also agree that any consult reports/x-ray results or any other important documents regarding myself/child be released to OrthoProActive Consultants Inc. upon request.
*
Yes
No
I have been informed that if any orthotic device(s) will be prescribed for myself/child that I may be responsible for a portion or the full cost of the orthotic devices (depending on if ADP funding is available.) ADP will cover 75% if the client has a valid Ontario Health Card, and if a Pediatrician or Specialist has signed the ADP for the specific device. The remaining 25% is my/ parents/guardians responsibility. If you are receiving social assistance for yourself/ child ( ACSD, ODSP, OW), we will bill the 25% directly to them. Please note that we require a copy of the current monthly statement that you receive from any of the mentioned social assistance groups.
Yes
No
I am aware that I have a choice to receive my device from any registered vendor in Ontario https://www.ontario.ca/page/garments-pumps-and-braces#section-4
*
Yes
No
General maintenance on an Orthosis(es) under normal use will be covered for a period of 6 months. I am aware that repairs that need to be made after 6 months from the date of fitting will be the client's responsibility to cover the cost.
*
Yes
No
I have read and understand the information provided above and I agree to have myself/ child assessed by a Certified Orthotist from OrthoProActive Consultants Inc. I am also aware that I am responsible for part or all of the cost for the orthotic device(s) that is/are required for myself/child. I am aware that if I do not provide all the required information, I will be responsible for the full cost of the device. I am aware there are no refunds for custom made devices.
*
Yes
No
Thank you for completing this form
