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Forms

Intake Form

Welcome to the healthcare management group inc.! In order to serve you better, please take a moment to complete this form, if you require assistance, please call or email the office.

Initial Intake Form

Patient Information (please complete all of the fields below)

Accident/Injury (Mva, Slipfall, Wsib)

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Have You Ever Been A Patient Before?

If Yes,Then When?

How Do You Learn About Us? ( If Referred, Please Name The Referral )

Patient Information

(Complete all the fields below)

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First Name

Last Name

Street Address

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Home Tel.

City / Town

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Provience

Postal Code

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Work Tel.

Date Of Birth

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Gender

SIN

Mobile

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Name Of Emergency Contact

Emergency Contact Tel.

Relationship

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Name Of Family Doctor

Family Doctor Tel.

Patient’s Email

Case Information

(Please Tell The Reason For Your Visit And Complete All The Related Information)

Automobile Accident

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Date of Accident

Name of Automobile Insurance Company

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Have You Already Reported Your Injuries To The Insurance Company?

Were You Employed At The Time Of The Accident?

Do You Have A Legal Representative? ( If Yes Please Provide The Name)

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Do You Have Extended Health Care Benefits Coverage? ( If Yes Please Provide Name Of Insurer )

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Work Injury

work injury

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Date of Accident

Clain Number ( if known )

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Nurse Case Manager

Tel.

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Wsib Adjudicator

Tel.

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Do You Require Treatment As A Result Of Work Related Injury?

Other

Patient Signature

(Please Print Your Name, Sign And Signature)

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

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Name of the Patient

Signature

Date

Please Provide The Following Documents

Driver's License
Health Card (OHIP)
Police Report
Insurance Pink Slip
Extended Health Benefits Card

Others

Please Note That 24-Hour Appointment Cancellation Notice Is Required To Avoid Charges

HCMG

Address: 303-330 HWY 7 East, Richmond Hill, ON L4B 3P8
Telephone: 905-882-1006 | 905-882-1007
E-mail: admin@hcmg.ca

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Forms

Intake Form

Patient Information (please complete all of the fields below)

Accident/Injury (Mva, Slipfall, Wsib)

Patient Information

Case Information

Patient Signature

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

Please Note That 24-Hour Appointment Cancellation Notice Is Required To Avoid Charges

HCMG

All rights reserved. HCMG 2024