Intake Forms

Physiotherapy and Massage Therapy Forms

Before your first appointment, please complete the forms below, print them out and bring them to the receptionist when you check in. Alternatively, you can arrive 10-15 minutes early for your first appointment and fill them out at the clinic.

For new physiotherapy patients

Please fill out these two forms required for all new physiotherapy patients:

• Patient Registration Form
• Physical Therapy Medical History Form

Then also fill out the forms below that are appropriate for your injury or condition:

• Neck Disability Index
• Oswestry Low Back Disability Questionnaire
• Upper Extremity Functional Scale
• Lower Extremity Functional Scale
• Acute Knee Injury Clinic (AKIC) Referral Form

For new massage therapy patients

Please fill out both of the forms below:

• Patient Registration Form
• Massage Therapy Patient History Form

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Performing Arts Clinic Forms

To book a session with the Performing Arts Clinic, please complete the Performing Arts Clinic referral form and fax it to the Glen Sather Sports Medicine Clinic at 780-407-5667.

You do not need a referral from a physician or therapist. The form above can be filled out by the individual requesting an appointment (self-referral). You will be contacted for an appointment once your referral form has been received. If you have an appointment booked, please bring the appropriate completed intake form with you to your first appointment:

• Musician Intake Form
• Musician Intake Form (Student)
• Dancer Intake Form

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Physician Referral Forms for other services

Sport and Exercise Medicine

Interested patients should have their physician complete the Sport and Exercise Medicine referral form and fax it to the GSSMC at 780-407-5667.

Complex Concussion Clinic

Interested patients should have their GP complete the Complex Concussion Clinic referral form and fax it to the GSSMC at 780-407-5667.

Comprehensive Osteoarthritis Management, Education and Treatment Clinic (COMET)

Interested patients with a confirmed osteoarthritis diagnosis should have their physician  complete the COMET referral form and fax it to the GSSMC at 780-407-5667.

Acute Knee Injury Clinic

The Acute Knee Injury Clinic is now accepting referrals from ALL primary care physicians and physical therapists with a PRAC ID number. MRI is not required for referral. Have your physician or physical therapist complete the Acute Knee Injury Clinic referral form.

Performance Rehabilitation

Have your physiotherapist or physician send an email to one of the participating therapists with 'Performance Rehabilitation' in the subject line:

• Bradley Green, MScPT, BKin, bjg@ualberta.ca
• Ryan Williams, BScPT, FCAMPT, Diploma Sport PT, rtw3@ualberta.ca

Functional Knee Injury and ACL Injury Clinic

Referral is usually made from the sport and exercise medicine physician, a physiotherapist or an orthopedic surgeon in the Glen Sather Clinic.

Referrals to the ACL Clinic can be made by a sports medicine and exercise doctor or a physical therapist from the Glen Sather Clinic.

Shoulder Injury Clinic

Referrals to these clinics can be made from the Glen Sather Clinic physiotherapist or sport and exercise medicine physician.