Complete the appropriate Form to help us initiate your Treatment Facility Locations Options and Patient Advisory Report Resources for future submissions to your Primary Care Giver, 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.

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 Care Giver 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 Care Giver and Specialists.

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

Motor Vehicle Accident - MVA Intake Form

How did you hear about us?

Please select ALL that applies:

Today's date

MM

DD

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email

Date of Birth

MM

DD

YYYY

Gender

OHIP Number

Please provide your OHIP Number and VERSION CODE

Doctors Information

Please provide your Family Doctor's NAME - TEL - ADDRESS

Accident Details..

Select all that applies - Tell us a bit more about your accident..

Date of Loss

Please provide the date of the accident

MM

DD

YYYY

MVA Insurance Information (Motor Vehicle Accident)

Please provide your Auto Insurance Information including INSURANCE COMPANY NAME - POLICY - CLAIM NUMBER - ADJUSTER'S NAME /TEL NUMBER/ADDRESS

EHC Insurance information (Private Extended Health Care)

Please provide your Private Extended Health Insurance Provider's Information as follow: INSURANCE COMPANY NAME - POLICY - CLAIM NUMBER - ADJUSTER'S NAME /TEL NUMBER/ADDRESS

Accident Desctiption

Please provide a brief description of the accident

Sports Injury Intake Form

Today's Date

MM

DD

YYYY

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

OHIP Number

Please provide your OHIP Number and VERSION CODE

Doctor's information

Please provide your Doctor's NAME - TEL NUMBER - ADDRESS

Accident details

Please provide a short description of accident/injuries

Date of Loss

Please provide the date of the accident

MM

DD

YYYY

ECH Insurance (Private Extended Health Insurance )

Please provide your Private Extended Health Insurance information as follow: INSURANCE COMPANY NAME - POLICY NUMBER - CLAIM NUMBER - ADJUSTER'S NAME - TEL NUMBER - ADDRESS

How did you hear about us?

*2. 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?

For Personal Injuries Medical Consultation special Requests - Subjective injuries & symptoms

Treatment requirements - Tell us what type of treatment you are seeking

*3. Consent Form - Give us permission to discuss your case with specific parties such as your Primary Care Giver, Specialists, Insurance Company and Lawyer... - You must complete this section in order for us to help you with your 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 and to only those pre-existing conditions that have been aggravated by the accident. 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....

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)

*4. 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”.

To provide Medical Records, Medical Reports & Imaging Reports such as XRay, Ultrasounds, CT Scans, MRI etc... ; please email them to contact@InteractHealthPRO.com

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

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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 Care Giver, Specialist or Referring Practitioner.