Markham Online Intake Form













Yes I agree



















Insurance Information

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




Insurance Coverage

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












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.