TELEREHAB CONSENT FORM

Direct Billing - Motor Vehicle Accidents - WCB

Telerehab Consent Form

Please review our telerehab terms of service before signing.

Name*
First Last
Birthday*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City Province Postal Code
Email

{optional but recommended)
Phone*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Website Privacy Policy*
I have read and agree to the website privacy policy.
Telerehab Policy & Terms of Service*
I have read and agree to the telerehab policy.
Consent to Email Contact
Yes (you can opt out at any time)
This includes information about upcoming appointments and updates to clinic services
Patient Signature*
Witness Name*
First Last
Witness Phone Number*
Witness Signature*