Forms

Get a head start on your first appointment by getting your paperwork out of the way ahead of time, with our easy-to-use online registration system. Visit the patient portal website Juvonno to complete your forms online today! Juvonno is a secure website and all of your  personal information will be kept safe and private, accessed only by Haley Rehab staff. Please complete the forms before your first appointment. If you are unsure of which forms to complete, please contact our receptionist at 613.422.5061 or admin@haleyrehab.ca If you are unable to access the Juvonno website, please print off and complete the following forms (some forms can be completed electronically):

Physician Referral form

To be completed by a health care provider, if you require a referral to access extended health insurance benefits.
Physiotherapists and massage therapists are direct practitioners and do not require a referral. However, some extended health benefit plans do require a doctor’s referral before they will cover your physiotherapy or massage therapy treatment. Check with your health benefits plan for details.

General Health History form

To be completed by all new clients.

General Health History – Yearly Update form

To be completed by repeat clients.

Outcome measures forms:

Upper Extremity Functional Index (UEFI) form

To be completed if you have upper body issues.

Lower Extremity Functional Index (LEFI) form

To be completed if you have lower body issues.

Neck Disability Index (NDI) form

To be completed if you have neck issues.

ISAEC Intake Form 1

To be completed, along with Intake Form 2, if you are seeing our ISAEC therapist, Angelo, for back issues.

ISAEC Intake Form 2

To be completed, along with Intake Form 1, if you are seeing our ISAEC therapist, Angelo, for back issues.

Lymphedema Questionnaire

To be completed if you have lymphedema or have undergone a lymph node dissection.