Please choose the applicable client form below. Once you click on the link, it will open in a new window and you will be able to print out and complete the forms included.
As well, please note that if you are under 18 years of age, you will need a parent or legal guardian to fill out the forms on your behalf before attending the initial appointment.
If you have any questions in regards to the forms, please contact our Active Physio Works clinics directly by calling 780-458-8505.
Initial Physiotherapy Assessment
- Informed Consent & Assignment of Payment
- Payment Arrangement
- Private Assessments also need to complete the Opting Out Form
Motor Vehicle Accidents
- Informed Consent
- Alberta Accidents Benefits Initial Claim Process (AB-1)
- Diagnostic and Treatment Protocols Authorization
- Auto Accident Report Form
Extended Health Care Forms
* Please note that some extended health care companies may require a medical referral or physician prescription (which is dependant on your provider and plan). If you ever unsure if this is required, it is always best to contact your Extended Health Care company first. Contact numbers for each of the companies we direct bill to are included below.
- Alberta School Employee Benefit Plan (ASEBP)
General Inquiries – 780-438-5300
- Great West Life & Send Payment Great West Life Form (has the cheque issued from GWL and sent directly to our office)
General Inquiries – 1-800-957-9777
- Green Shield
General Inquiries (head office) – 1-519-739-1133
- Blue Cross (requires no form on file for direct bill, please bring in a copy of your valid Blue Cross card as we are able to offer online direct billing if claims are submitted within 30 days).
General Inquiries – 780-498-8000
- Sunlife Electronic Submission & Consent for Direct Billing (Please note we cannot direct bill to Public Service Health Care plans at this time)
- Manulife (must have direct billing set up for your plan before direct billing can be completed at our clinics)
General Inquiries - 1-800-265-9977
Acupuncture & IMS