Markham Online Intake Form

Thank you for filling out our convenient online intake form. This will help us serve you faster upon your arrival. This only takes a moment.


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    Insurance Information

    To help you with insurance coverage, please provide us with the following information.
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    Insurance Coverage

    What is your maximum coverage ($) for the following?
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    Patient Agreement

    I understand that that any missed appointments that are not cancelled within 24 hours of the appointment time will be charged as a regular visit. I hereby authorize Form & Function with my prior knowledge, to release to or obtain any health information from my other healthcare providers as may be required for: • Providing health care; • Advising you of treatment options • Establishing and maintaining contact with you regarding appointments invoicing and follow-up care; • Sending you pertinent information and mailings; • Facilitating your insurance claims; • Allowing potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale; • Complying with the legal and regulatory requirements of the Drugless Practitioners Act. I have read and understand the Form and Function privacy policy and cancellation policy. I am aware that if insurance claims are being submitted on my behalf that I am responsible for any outstanding balance not covered by my insurance policy
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