Adult Functional Health Intake Form

My annual deductible is:

	Amount
Individual
Combined

I have the following coverage:

	Naturopathic Medicine	Chiropractic	Massage	Acupuncture	Physiotherapy	Counsellor or Psychologist **
$ TOTAL coverage per benefit period (i.e. per year)
% covered per billing
$ maximum per INITIAL visit
$ maximum per SUBSEQUENT visit
Doctors note required?

** If yes for Counsellor or Psychologist, my insurance company accepts:

Psychologists Registered Clinical Counsellors Registered Therapeutic Counsellors

I have the following coverage:

	Custom Made Orthotics	Compression Hosiery/Stockings
% Coverage
$ maximum per benefit period
# pairs per benefits period
Who needs to prescribe

The compression I'm covered for is:

Custom Made Orthotics

	Yes	No
Rolling Months
I need a biomechanical assessment
I need a GaitScan Analysis
I need a 3-D Cast
A Chiropractor dispense my orthotics

The number of rolling months is:
I have a fitness spending account (Yes or No), if Yes, how much per year?
I have a Health Spending Account (that I can use for whatever services/product I wish)? If Yes, how much?
Under Naturopathic Services, I am additionally covered for LABS? if yes how much extra? OR is it included in the maximum for ND Services?
Under Naturopathic Services, I am additionally covered for SUPPLEMENTS? if yes how much extra? OR is it included in the maximum for ND Services?
Any other additional information about your benefits that would be useful for us in helping you with your health plan?
Thank you very much! Once submitted, this information will go straight to our front desk team. If you would like a copy of the completed form, please contact us!
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EXTENDED HEALTH CARE COVERAGE FORM