Complete the appropriate Form to help us initiate your Treatment Facility Locations Options and Patient Advisory Report Resources for future submissions to your Primary Caregiver, Specialist or Referring Practitioner.

In order to “Help us Help you” some primary information as well as more specific information is required. Simply complete the forms that are related to your condition and we will be happy to assist you within 24 hours of submission.

If someone is already helping you, you only need to complete *1. Consent Form

Once we receive the completed forms, someone will contact you to assist you further with your rehabilitation needs. IHP’s dedicated and compassionate co-coordinators will help you select the most convenient location for your specific needs taking into consideration recommendations from your Primary Caregiver for your condition and treatment needs as well as your ability to continue to work or not and where you live in the GTA.

We will then submit a request to the selected treatment facility to provide a New Patient Advisory Report and Progress Reports which will be sent directly to your Primary Caregiver and Specialists.

*1. Consent Form - Give us permission to discuss your case with specific parties such as your Primary Caregiver, Specialists, Insurance Company and Lawyer... in order to provide you with the best possible Professional Options Resource & Services. You must complete this section in order for us to help you with your treatments & rehabilitation needs

CONSENT & DISCLAIMER

Today's Date

MM

DD

YYYY

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Email

CONSENT: I Authorize Interact Health PRO to give my Insurance Company and/or Family Physician (or Health Practitioner, Occupational Therapist, Rehabilitation Consultant, Social Worker, Legal representative or Agency), to provide and/or obtain any information relating to my health condition and treatment received as a result of the automobile accident/collision, sports injury or acute/chronic pain condition and to only those pre-existing conditions that have been aggravated by the accident or acute/chronic condition. I also, hereby authorize any person or agency having medical, vocational or other information pertaining to my disabled condition to release such information to Interact Health PRO, for their use in assisting my rehabilitation.

DISCLAIMER: I have read and understand Interact Health PRO's Disclaimer.

The information offered on this website, inclusive of but not limited to text, images, links and other materials are avaialable to you for informational purpose only. This information should not be taken as advice or specific treatment recommendations; nor should it be used under any circumstances for diagnostic purposes. Please visit a qualified healt care practitioner for diagnoisis and treament of health-related condition you may need to address; treatment and results may vary from person to person.

Signature & Location

I AGREE to the CONSENT and DISCLAIMER described in this form; signed at the City of________________ (please write the name of the city you are currently signing this form at)

Personalized Forms

*2. Please select the most appropriate forms for your specific needs: Please select ONE only

*3. Treatment requirements - Tell us what type of treatment you are seeking - you may choose from all options

Professional Requests:

*3. Personal Injuries Medical Consultations & Assessments - Please select the appropriate Consultation & Medical Report you are seeking - you may choose from all options

Occupational Therapy - Assessment Request

Today's Date

MM

DD

YYYY

Name

First Name

Last Name

Email

Please select the required Occupational Therapy Medical Consultation/Assessment

Please select ALL that applies

In Home Assessment

Attendant Care Needs – Form 1

Job Site Assessment – JSA/PDA

OT Educational & Intervention Sessions

Assistive Devices Program

Mental Assessment

Referral Source

Please provide the NAME and PHONE NUMBER of the Doctor, Practitioner, Rehabilitation Centre or Law Firm who recommended and/or requested these Medical Assessments & Consultations

Did you complete an OCF-18 Treatment and Assessment Plan for this request?

Vocational Evaluation Request

Name

First Name

Last Name

Email

Today's Date

MM

DD

YYYY

Please select the required Vocation Evaluation or Medical Consultation/Assessment

Please select ALL that applies

Transferable Skills – TSA

Labour Market Analysis – LMS

Speech Language

Social Worker

Psycho-Vocational

Psycho-Educational

Ergonomics

Jobsite Assessment

Referral Source

Please provide the NAME and PHONE NUMBER of the Doctor, Practitioner, Rehabilitation Centre or Law Firm who recommended and/or requested these Medical Assessments & Consultations

Did you complete an OCF-18 Treatment and Assessment Plan for this request?

Diagnostic Imaging Request

Today's Date

MM

DD

YYYY

Name

First Name

Last Name

Email

Please select the required Imaging Medical Consultation/Assessment

Please select ALL that applies

MRI

CT Scan

X Ray

Referral Source

Please provide the NAME and PHONE NUMBER of the Doctor, Practitioner, Rehabilitation Centre or Law Firm who recommended and/or requested these Medical Assessments & Consultations

Did you complete an OCF-18 Treatment and Assessment Plan for this request?

*4. Injury Subjective & Symptoms - Tell us about your injuries and symptoms

*6. Contact Confirmation E-mail - You will receive an email to confirm someone will contact you within 24 hours. “Please ensure your e-mail address and telephone number are correct”.

Complete the appropriate Form to help us initiate your Treatment Facility Locations Options and Patient Advisory Report Resources for future submissions to your Primary Caregiver, Specialist or Referring Practitioner.

Personalized Forms

Professional Requests:

Your ALL in ONe “virtual” Pain Management Solution!

You don’t have to live with Pain…

“Gain Pain Relief”

with Interact Health PRO Virtual Care!

100+ Affiliate Rehabilitation Centres across the GTA

Intake & Consent Forms

Complete the appropriate Form to help us initiate your Treatment Facility Locations Options and Patient Advisory Report Resources for future submissions to your Primary Caregiver, Specialist or Referring Practitioner.

Personalized Forms

Professional Requests: