Man filling out paperwork

New Patient Forms at
Perth Family Health Centre

Save time during your first visit

To help us focus our time on your health please complete this paperwork before your first visit and either bring it with you or fax or e-mail it in.

Chiropractic Forms

New Chiropractic Patient Health History Form
Chiropractic Personal Information Form

Massage Forms

Massage Intake Form

Patient Privacy Consent Form

For Collection, Use and Discloser of Personal Information

Privacy of your personal information is an essential part of our office providing you with quality care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your information responsibly. We also try to be as open and transparent as possible about the way we handle your paper information. It is important to us to provide this service to our patients.

In this office, the Privacy Information Officer is:

Dr. Warren Hollis

All Staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

In this consent form, we have outlined what our office is doing to ensure that:

Only necessary information is collected about you;
We only share your information with your consent;
Storage, retention and destruction of your personal information complies with existing legislation, and privacy protocols;

Our privacy protocols comply with the privacy legislation, standards of our regulatory body and the law.

Do not hesitate to discuss our policies with me or any member of our staff.

Please be assured that every staff person in our office is committed to ensuring that you receive the best quality care.

How Our Office Collects, Uses and Discloses Patients`Personal information

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined below how our office is using and disclosing you information.

This office will collect, use and disclose information about you for the following purposes:

To deliver safe and efficient patient care
To identify and to ensure continuous high quality service
To assess your health needs
To provide health care
To advise you of treatment options
To enable us to contact you
To establish and maintain communication with you
To offer and provide treatment, care and services
To communicate with other treating health-care providers, including specialists and referring doctors
To allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
To allow us to efficiently follow-up for treatment, care and billing
For teaching and demonstrating purposes on an anonymous basis
To complete and submit claims for third party adjudication and payment
To comply with legal and regulatory requirements, including the delivery of patients`charts and records to governing bodies in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
To comply with agreements/undertakings entered into voluntarily by the member with governing bodies, including the delivery and/or review of patients
To permit potential purchasers, practice brokers or advisers to evaluate the practice
To allow potential purchasers, practice brokers or advisers to conduct an audit in preparation for a practice sale
To deliver your charts and records to the office’s insurance carrier to enable the insurance company to assess liability and quantity damages, if any
To prepare materials for the Health Professions Appeal and Review Board (HPARB)
To invoice for goods an services
To process credit card payments
To collect unpaid accounts
To assist this office to comply with all regulatory requirements
To comply generally with the law

By signing the consent section of this Patient Consent Form, you have given your informed consent to the collection, use and/or disclosure of your personal information,for the purposes that are listed. If a new purpose arises for the use and/or disclosure of our personal information, we will seek your approval in advance.

Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) and for the defense of legal issue.

Our office will not under any conditions supply your insurer with you confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.

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