Intake Form

  • Date Format: MM slash DD slash YYYY
  • Is the injury you are being treated for today a result of:

  • I consent to physiotherapy assessment at West Physio. As a patient of West Physio, I amfully aware that I am responsible for payment of my physiotherapy treatments. I understandthat cancelling my appointment with less than 24 hours notice or missing an appointment willresult in a charge of a treatment fee.
  • I consent to receive email communication for the purpose of appointment reminders:
  • Date Format: MM slash DD slash YYYY