Registration Form

I would like to receive appointment reminders via: *

Email Text Both No reminders please

I do NOT wish to receive emails from Mackie Physiotherapy *

No emails please

Fee For Service/Group Insurance Plan
This clinic is a fee-for-service clinic. I, the patient, will pay Mackie Physiotherapy for my treatment directly, and, if applicable, will submit the receipt to my group insurance plan for coverage of the treatment expense unless previously done so electronically by the clinic. Please indicate your understanding of this by checking below.

Third-Party billing
This clinic will bill WCB, SGI, DND, DVA, and RCMP claims directly as long as it is pre-approved by the insuring party. I, the patient, understand that I am responsible if these agencies do not accept responsibility for payment. My electronic signature below allows Mackie Physiotherapy to relase assessment and treatment information to the insuring party when it is requested or when the physiotherapist deems it necessary. Please indicate your understanding of this by checking below.

WCB Patients Only:

Employer Contact Person *

Contact Person Phone Number *

Contact Person Fax Number *

Cancellation/Missed Appointments
Mackie Physiotherapy reserves the right to charge a fee for missed appointments, or for appointments that are cancelled with less than 24 hours notice. These fees are to be paid by the patient, not by an insuring party. Please be respectful of the clinicians, the clinic, and your rehab process and make every effort to attend your scheduled appointments. Please also be aware that, as the clinic is very busy, it is difficult to reschedule appointments.

Cancellation fee for cancellations occurring with less than 24 hours notice is $20.
Missed appointment fee will be the full cost of the appointment.

IF YOU ARE EXPERIENCING ANY COVID-19 SYMPTOMS, PLEASE LET US KNOW AND WE WILL CANCEL YOUR APPOINTMENT AND REBOOK YOU FOR A LATER DATE.

Please explain any of the above answers that require further explanation. *

Mackie Physiotherapy Registration Form

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