Medilink Physiotherapy Self-Referral Form

Tel. 778-590-7050 Fax. 778-590-7050
102/ 104- 8232 120 Street, Surrey BC V3W 3N4
www.medilinkconsulting.ca

First Name, Last Name

Address & Email

Phone number

Date of Birth

MODALITY OF PAYMENT

Extended Medical Benefit (Name & Plan#)

Private

Others ( ICBC, WCB... claim number)

YOUR PROBLEM

Motor vehicule accident

Work-related injury

Sport injury

Post surgery

Others: (Please indicate)

A. When did it start?

B. Scale of pain: 1- 10 ( 10 being the highest)

C. Where is the problem ( please tick on the diagram)

.

Additional comments

Initials

Today's date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Medical Clinic in Delta, British Columbia

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