New Patient Form

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Home
Services
Dr. Jason Mazzarella
Dr. Katherine Marek
Contact
Whiplash CE Seminars
Education

Home
Services
Dr. Jason Mazzarella
Dr. Katherine Marek
Contact
Whiplash CE Seminars
Education

New Patient Intake Online Submission Form

Due to the COVID 19 Epidemic, we are currently offering an online Initial Intake Portal for New Patients.

As a new patient we require certain personal and health information to ensure that you receive the best possible care.

You have the option to complete the paperless form to the right, or print off the forms below and bring them with you to you first appointment.

Universal Health & Rehabilitation

Intake New Patient Paperwork

Name*

Email Address*

Address*

Telphone

Marital Status

Gender

Reason for Visit

How did you here about us?

Work Information (employer name and address)

Insurance Information (Company Name, Provider Number, Group Number)

What Service are you Interested In?

ChiropracticAcupuncturePhysiotherapyMassage TherapyVestibular RehabilitationConcussion TherapyPain ManagementWellnessNutritionExercise / KinesiologyOrthoticsPostural ImprovementOther

Current Primary Complaint

Past Medical History

Are you Pregnant

I have read and agree to the Chiropractic Consent Form on this website

YesNo

I have read and consent to the Acupuncture Consent Form on this website

YesNo

I have reviewed the COVID 19 Policies and Clinic Procedures Form on this Website

YesNo

Additional Information you would like us to know.

This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.

Thank you for contacting us. We will get back to you as soon as possible

28 Finch Avenue West, Suite 212, Toronto, Ontario M2N2G7

T: (416) 628-1336. E: [email protected]