If you are a new patient to our clinic, welcome!
While we understand that filling out forms is never fun, we ask that you please make sure to be as accurate and detailed as you can. The information you provide will give the practitioner treating you a clear picture of your medical history, and will allow them to make a more complete assessment.
If you have any questions, or need help filling out any of the below forms, please feel free to call our office at 604-732-3422. One of our staff will be happy to assist you.
New Patient Forms
If this is your first treatment with Dr. Larsen, you can save time by filling out the Patient Info Sheet prior to arriving at the office. Once done, you can either email us the completed form, or bring a printed copy with you. You won’t need to print the Informed Consent and the Fees and Policies forms, but you are welcome to read through them ahead of time.
If you would prefer to complete the Patient Info sheet at the office, we ask that you please arrive 15 min before your scheduled appointment time. This will ensure enough time to complete the paperwork before the start of your appointment.
Please note that treatment cannot take place until you have completed and signed the below forms.
Benefit Assignment Form and Authorization
If you have coverage with any of the providers listed below, please let staff know at the beginning of your appointment. You can also read through, and fill out the Authorization form before arriving at the office. This will allow us to bill on your behalf.
Pacific BlueCross, Canada Life (Great West Life), Manulife Financial, EquitableLife, Claims Secure, Desjardins Insurance, Industrial Alliance, Johnson Inc, Johnston Group, Cowan, Manion, Chambers of Commerce Group Insurance Plan, Group Health, Group Source, First Canadian, and Maximum Benefit
NOTE: Effective November 26, 2021, SunLife Financial will no longer be accessible through the TELUS Health eClaims service.
If you have previously been treated by Dr. Larsen, but have not been in for treatment for a period of 6 months or more, please fill out the Update form, and read through the Informed Chiropractic Consent.
If you are unable to complete the Update forms prior to your arrival at our office, we ask that you arrive 5 minutes before your scheduled appointment time. This will ensure enough time to complete the paperwork before the start of your appointment.
Please note that treatment cannot take place until you have completed and signed the above forms.
If you have recently been in a motor vehicle accident, or have an ongoing ICBC claim, please fill out the ICBC Questionnaire.
The last three pages of the intake form are required surveys by ICBC. Please ensure that you are as accurate as possible and complete all boxes that apply. Keep in mind that the Neck Disability Index only applies to neck pain (only complete if you have neck pain), and the Back Pain Disability Index only applies to back pain (only complete if you have back pain).
If you have recently been in a work place accident, or have an ongoing WorkSafe claim, please fill out the WorkSafe BC Questionnaire prior to arriving at the office.