Templates · Free template · Physiotherapy
Physiotherapy Patient Intake Form Template
A printable physiotherapy intake form that collects the history, goals, and funding information before the first visit, so the assessment can start on the problem instead of the paperwork.
Collect what the first visit needs
The best time to gather history is before the appointment. Sending the form ahead means the visit starts with clinical questions rather than forms, and your assessment can use the answers.
Ask about the funding source up front: extended health, WSIB, or auto insurance each need different paperwork. Include consent to assessment and treatment and to communication by phone or email.
Physiotherapy Patient Intake Form
Client
Presenting problem
History
Funding
- Private / self-pay
- Extended health insurance
- WSIB / workers' compensation
- Motor vehicle insurance
- Other
Consent
Signatures
Template from zdrovia.ca/templates/physiotherapy-intake-form/ · Review with your medical director, regulatory college guidance, and insurer before use.
Send this form before the appointment instead of printing it
Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.
See how Zdrovia is set up for physiotherapy clinics.
Frequently asked questions
Can intake be done online?
Yes. Most clinics send it before the first visit so it can be reviewed in advance.
What about privacy consent?
Follow your province's health privacy law and your college guidance on consent and information sharing.
Related
This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.