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Patient Forms

Our Patient Intake Packages are available by clicking the buttons below.  You have the option of downloading and filling the forms manually or using the online fillable format which can be printed or saved and emailed directly to us at admin@spinegroup.ca.  Please provide as much detailed information as possible on the Patient Intake Form and bring it with you to your first appointment along with any relevant diagnostic reports. Consent Forms must also be completed and returned to the clinic with original signatures. There are separate packages for Private Patients, OHIP Physiotherapy Patients and Rapid Access Clinic for Low Back Patients.

Note: Please also complete the appropriate Outcomes Measures for your injury/condition. Included below are outcome measures for Back, Neck  Lower Extremity and Upper Extremity Complaints.   

Surveys, including SPINEgroup’s Patient Satisfaction Survey and RAC LB surveys for both virtual and in person assessments can also be found below

Forms

OHIP Physiotherapy Intake Package

Download Form

Private Patient Intake Package

Download Form

RAC Low Back- Intake Package

Download Form

RAC Low Back- Follow Up Form

Download Form

Outcome Measures

Low Back Pain

Download Form

Lower Extremity Pain

Download Form

Upper Extremity Pain

Download Form

Neck Pain

Download Form

Surveys

Patient Satisfaction Survey

Download Form

RAC Low Back Satisfaction Survey

Access Online Survey

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Monday, Wednesday, Friday 9 AM - 5 PM
Tuesday, Thursday 12 PM - 7 PM
*Saturday (Alternating) 9 AM - 1 PM
*Saturdays *Virtual Appts Only

© 2024 Dr. Connie D’Astolfo Chiropractic Professional Corporation. All rights reserved. | SPINEgroup®

Privacy Policy
Terms of Use
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Access to Secure Patient Portal

Current patients can now book appointments online in real time through our secure patient portal. MySPINEgroup Patient Portal is a free online tool that also allows you to access your health information securely from your personal device (phone, computer, tablet etc.).  Log on to any computer, from anywhere, at any time, to stay on top of your health information, including lab test results, booking and rescheduling appointments, complete questionnaires, view medication prescriptions, access your exercises, track your health and more.

To log on for the first time, you will need your “Portal Key” in order to register. (Your portal key needs to be sent to you via email or text from SPINEgroup). When registering please write your name exactly how it appears on your health card.  Once registered you will have your personal username and password to log in into your portal.

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Privacy Policy

SPINEgroup® Privacy Policy

This Privacy Policy describes the collection, use and disclosure of Your Information in connection with Your Interaction with Dr. Connie D’Astolfo Chiropractic Professional Corporation trading as SPINEgroup® (“SPINEgroup®” or “We” or “Us”) in the course of providing Healthcare Services.

When engaging in any Interaction whether or not You have requested or received any of the Healthcare Services offered by Us, You consent to the collection, transfer, manipulation, storage, disclosure and other uses of Information as described in this Privacy Policy. We seek to minimize our collection and use of Information to what is needed for providing Healthcare Services.

Please note that this Privacy Policy does not apply to the collection, use, management, disclosure and destruction of Your Information by Permitted Healthcare Personnel. Please note that Permitted Healthcare Personnel are subject to separate privacy legislation and professional and/or regulatory requirements in Ontario that govern the collection, use and management of Your Information in the course of providing Healthcare Services to You. Please contact the respective Permitted Healthcare Professional directly if You have any questions or concerns about their specific collection, use or management of Your Information in relation to the course of Your Healthcare Services.

This Privacy Policy is in accordance with the Personal Information Protection and Electronic Documents Act (“PIPEDA”), the federal privacy law for private-sector organizations. We will seek to ensure compliance with PIPEDA, as amended by the Digital Privacy Act (“DPA”), as may be applicable, as well as with the Personal Health Information Protection Act (“PHIPA”), where applicable. We are committed to complying with this Privacy Policy.

Definitions:

“Dependent” means any individual for whom You have the legal authority to make decisions regarding Healthcare.

“Healthcare” means any services or virtual services relating to the maintenance or improvement of an individual’s health to prevent, diagnose, treat, recover or cure such individual’s disease, illness, injury, and other physical and mental impairments.

“Healthcare Services” means the Healthcare services provided by Us via the Patient Platform, in-person, virtually or otherwise.

“Information” shall mean Personal Information and may include PHI as the circumstances may require.

“Interaction” means any contact between You and us (unless excluded herein) whether transmitted via the Patient Platform, facsimile, electronic correspondence, email, texts, verbally and/or in-person patient encounter.

“Personal Health Information” or “PHI” means identifying information, recorded in any form, about You, if the information relates to: (a) Your physical or mental health (including health history), (b) the provision of Healthcare to You (including the identification of a person as Your provider of Healthcare), (c) Your payments, eligibility or coverage for Healthcare, and/or (d) Your health number.

“Permitted Healthcare Personnel” means, in the Province of Ontario, (a) authorized physicians licensed to practice medicine in the Province of Ontario, (b) authorized regulated healthcare professionals licensed in the Province of Ontario to provide Healthcare Services, and/or (c) healthcare administrator staff employed or working for Us.

“Personal Information” means information, recorded in any form, about an identifiable individual which is not PHI being collected, created, compiled, used, disclosed by means of the Patient Platform, entered by Us or uploaded by You.

“Patient Platform” means, inter alia, the hardware, applications, websites including www.spinegroup.ca, portal and services owned and/or operated by Us but not third-party sites or software.

“You” or “Your” also refers to you on behalf of your Dependent(s), where applicable.

Collection of Personal Information

a) Any Interaction may result in our collection of Personal Information. We collect Personal Information directly from You, or indirectly from third party sources as otherwise permitted by applicable law.a) Log Data: Our servers may record certain information (“Log Data”) related to Your actions on the Patient Platform. Log Data may include information such as Your IP address, browser type, ISP, date/time stamps, the referring domain, and pages visited. Log Data may also be recorded by third parties.

b) Cookies: We may use “cookie” technology to collect any additional Patient Platform usage data and to improve our Healthcare Services. A cookie is a small data file that is transferred to Your computer’s hard disk. Most Internet browsers automatically accept cookies. You can instruct Your browser, by editing its options, to stop accepting cookies.

c) Submissions: Any information such as remarks, suggestions, questions, correspondence, comments, creative ideas, photos, graphics, or other information communicated to Us (collectively, called the “Submission”) shall be treated as non-confidential. You agree that You will not upload or transmit any Submission that infringes any patent, trademark, trade secret, copyright or other proprietary rights of any party in the world. Your Submission becomes the property of SPINEgroup and We shall be free to use the Submission on an unrestricted basis for any purpose whatsoever.

d) Third-party Services: We may use a variety of services hosted by third parties to help provide our Healthcare Services. These third-party services may collect information sent by Your browser as part of a web page request, such as cookies.

e) Links: The Patient Platform may contain links to third party websites. These links are not intended as an endorsement of or referral to the linked websites. Please review all third-party privacy policies for any site you browse or visit.

Permitted Healthcare Personnel may, create, compile or print Information such as treatment plans, prescriptions, and clinical notes in relation to any Interaction with You (collectively the “Patient Notes”) as necessary to provide Healthcare Services and to comply with applicable laws. While providing You with Healthcare Services, Permitted Healthcare Personnel may also collect additional Personal Information about You. Subject to Your withholding rights as noted below, Permitted Healthcare Personnel will have access to the Personal Information. Such Personal Information may include but is not limited to: details You provided, documents, Patient Notes created by others, and emergency contact information (please note that You are responsible for notifying Your emergency contact that You are providing their information to Us and for obtaining their consent).

Use of Your Information

When requesting Healthcare Services, You may be asked to provide Information regarding the Healthcare Services, Your medical history and applicable symptoms. Upon patient intake completion, We may disclose the identity of the Permitted Healthcare Professional to You. Afterwards, unless You have chosen to withhold access to any of Your Information to Us stored in the Patient Platform, the Permitted Healthcare Personnel assigned to You will be able to view such Information in order to provide Healthcare Services. Please note that in some circumstances, the withholding of Information may severely limit the Permitted Healthcare Personnel’s ability to provide You with Healthcare Services.

In addition to some of the specific uses of Personal Information we describe in this Privacy Policy, we may use or share such Personal Information to: (a) confirm Your eligibility to use the Patient Platform, or authenticate You when You log onto the Patient Platform, (b) if applicable, determine Your eligibility for Healthcare Services, (c) connect You to the appropriate Permitted Healthcare Professional, (d) establish, maintain and manage patient relations with You in order to provide Healthcare Services, (e) provide ongoing customer service to You, (f) facilitate payments for Healthcare Services, and (g) comply with meet any legal and regulatory requirements.

Information Sharing and Disclosure

Our use of Information is limited to the purposes described in this Privacy Policy, and We do not otherwise sell, rent, trade, barter, exchange or disclose for consideration any Information that we have obtained.

a) With Your Consent: We may share or disclose Your Information with Your consent. Consent can be either express (verbally, in writing or electronically) or implied, where permitted under applicable law. When You provide Your Information voluntarily or to a Permitted Healthcare Professional, You imply that You have consented to the collection, use and disclosure of such Information. You may change or withdraw Your/their consent at any time, subject to legal or contractual restrictions, if any, and reasonable notice, by contacting us at admin@spinegroup.ca. Please note that in some circumstances, a change in or withdrawal of consent may severely limit or prevent our ability to provide Healthcare Services.

b) Without Consent: Please note that there are circumstances where the use and/or disclosure of Your Information may be justified or permitted or where we are obliged to disclose information WITHOUT consent. Such circumstances may include, but are not limited to the following: (a) if we believe that it is reasonably necessary to comply with a law, regulation or legal request, (b) to protect the safety of any person; (c) to address fraud, security or technical issues; or (d) to protect our rights or property.

c) Other Service Providers: We share Information with Permitted Healthcare Personnel, Your emergency contacts, our employees, and contractors and business partners, to the extent required for them to provide the Healthcare Services to You or for the purposes in this Privacy Policy. We engage certain trusted third parties to perform functions and provide services to us such as website hosting companies, payment processing companies and other third-party service providers. We may share Personal Information with these third parties, but only to the extent necessary.

d) Corporate Transfers: In the event that we are involved in a bankruptcy, merger, acquisition, reorganization or sale of assets, Your Information may be disclosed or transferred as part of that transaction. The promises and exceptions in this Privacy Policy will apply to Your Personal Information as transferred to the new entity.

e) Government: We may share Personal Information with government agencies and law enforcement officials, when required to do so to respond to subpoenas, court orders or legal process, or to establish or exercise our legal rights or defend against legal claims.

 Protection of Information and Disclaimer

We endeavor to maintain appropriate physical, procedural and technical security with respect to our offices and Information storage and recovery facilities so as to prevent any loss, misuse, unauthorized access, disclosure, or modification of Information. We further protect Your Information and any financial or payment information by restricting its access to those employees and contractors who need to have knowledge of that Information in order for us to provide our Healthcare Services. While we endeavour to protect Your Information, no data transmission over the Internet can be guaranteed to be absolutely secure, and we cannot ensure or warrant the security of any Information You transmit to us via email or via the Patient Platform or otherwise; any transmission to Us is at Your own risk.

By this Privacy Policy, We shall hereby notify patients of the potential risks, including privacy-related risks, associated with the Patient Platform, and to obtain Your express consent to receiving Healthcare Services, You are hereby notified that: (a) certain Healthcare Services may be made available through third-party platforms, (b) use of the Patient Platform or using unencrypted SPINEgroup email from You or to You or others on your behalf, may increase the risk of Your Information being unintentionally disclosed or intercepted by third parties, (c) while We will make reasonable efforts to protect the privacy and security of Your Information, it is not possible to completely secure electronic correspondence or email to third parties including Your legal representative(s) and therefore the security and confidentiality of Information and Healthcare Services cannot be guaranteed, (d) You agree to take steps to protect Your privacy when receiving Healthcare Services including confirming Your identity with Permitted Healthcare Personnel, (e) using Healthcare Services only from a private location, on Your own computer or device, and on a password-protected Wi-Fi network, (f) not recording the Healthcare Services, or any part thereof, (g) You agree that We may collect location data through the use of GPS technology and Your IP address where applicable, (h) You agree that Information may be used or disclosed as permitted or required by law including any risk of harm to an individual or a child is in need of protection under the Child, Youth and Family Services Act, 2017).

Privacy Policy Changes

We may revise this Privacy Policy from time to time. The most current version of this Privacy Policy will govern the use of Information unless we notify You otherwise. Please check this page periodically for any updates. By continuing to access or use the Healthcare Services after those changes become effective, You agree to be bound by any revised Privacy Policy.

Contact Us

If You have any questions, concerns, or requests regarding Your Information or our Privacy Policy, please contact us at: 1-905-850-7746

Terms of Use

Terms of Use and Conditions

PLEASE READ THESE TOU AND CONDITIONS OF USE CAREFULLY BEFORE USING THIS SITE.

By using this website (“Site”), you signify your assent to these Terms and Conditions of Use (“TOU”). If you do not agree to all of these TOU, do not use this site!

Dr. Connie D’Astolfo Chiropractic Professional Corporation (“DCDCPC”) may revise and update these TOU at any time. Your continued usage of this Site will mean you accept those TOU changes.

THE SITE DOES NOT PROVIDE MEDICAL ADVICE. The contents of the Site, such as text, graphics, images, photos, trade-marks, information, data, logos, buttons, proprietary software icons, compilations (meaning the collection, arrangement and assembly), articles, forms, photos, blogs, updates, news, glossary, reviews, health tips, opinions and the collection, compilation and assembly thereof, overall look and distinctiveness and other material (collectively, the “Content”) contained on the Site are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your chiropractor, physician or other qualified primary health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on the Site!

If you think you may have a medical emergency, please call your family doctor or 911 immediately. DCDCPC does not recommend or endorse any specific tests, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by DCDCPC, employees, independent contractors or others appearing on the Site at the invitation of DCDCPC, or other visitors to the Site is solely at your own risk. You are solely responsible for compliance with the laws applicable to your jurisdiction of residence. Always consult your physician before beginning any exercise or treatment program. DCDCPC denies any responsibility or liability for any adverse consequences or damages resulting from reliance on the information contained in this Site.

Information is believed to be accurate at the time it was created. However, information or blogs may become outdated over time. Information on the Site may contain technical inaccuracies or typographical errors. Information may be changed or updated without notice. DCDCPC will use reasonable efforts to include accurate and up-to-date information on the Site but makes no warranties or representations as to its accuracy. All Users agree that all access to and use of this Site is at their own risk.

Advertising and Marketing Statement. Please note that the use of words “expert” and “specialty” on all SPINEgroup ® advertising does not specifically apply to physiotherapists or registered massage therapists or others providing care at our clinic; however, use of such terms, under some circumstances, is not inconsistent with Section 2 of the College of Chiropractors of Ontario (“CCO”) Standard of Practice “S-016- Advertising” when it comes to the design, implementation and evaluation of evidence-based programs of care or specialty programs of individualized care of Dr. Connie D’Astolfo which may or may not involve physiotherapists, registered massage therapists or others providing care.

CHILDREN’S PRIVACY. We are committed to protecting the privacy of children. You should be aware that this Site is not intended or designed to attract children less than 16 years of age. We do not collect personally identifiable information from any person we actually know is a child under the age of 16.

USE OF CONTENT. DCDCPC authorizes you to view or download a single copy of the material on the Site solely for your personal, non-commercial use if you include the following copyright and trademark rights notices “© 2009 Dr. Connie D’Asltofo Chiropractic Professional Corporation. All rights reserved. ║Spinegroup™” Title to the Content remains with DCDCPC or its licensors. Any unauthorized use of the Content not expressly permitted by these TOU is a breach of these TOU and may violate copyright, trademark, and other laws. Content and features are subject to change or termination without notice in the sole discretion of DCDCPC. All rights not expressly granted herein are reserved to DCDCPC and its licensors. If you violate any of these TOU and Conditions, your permission to use the Content automatically terminates and you must immediately destroy any copies you have made of any portion of the Content.

LIABILITY OF SPINEGROUP AND ITS LICENSORS. The use of the Site and the Content is at your own risk. When using the Site, information will be transmitted over a medium which is beyond the control and jurisdiction of DCDCPC and its suppliers. Accordingly, DCDCPC assumes no liability for or relating to the delay, failure, interruption or corruption of any data or other information transmitted in connection with use of the Site. The Site and the content are provided on an “as is” basis. DCDCPC, ITS LICENSORS, AND ITS SUPPLIERS, TO THE FULLEST EXTENT PERMITTED BY LAW, DISCLAIM ALL WARRANTIES, EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRD PARTIES’ RIGHTS, AND FITNESS FOR PARTICULAR PURPOSE. DCDCPC, its licensors and its suppliers make no representations or warranties about the following: the accuracy, reliability, completeness, currentness or timeliness of the Content. DCDCPC will not be responsible to you or to any third parties for any direct, indirect, consequential, special, or punitive damages or losses you may incur in connect with this service. You agree to indemnify, defend and hold harmless DCDCPC, its officers, directors, employees, agents, licensors, suppliers and any third-party information providers to this Site from and against all losses, expenses, damages and costs, including reasonable lawyer’s fees, resulting from any information you provide or from any violation of the TOU by you.

DISCLAIMER. DCDCPC is limited to only providing static health information. This Site does not provide any medical diagnosis, symptom assessment, health counseling or medical opinion for individual users. An enquiry to the Site should not replace a call to 911 – your first choice in the event of an emergency. If you are feeling ill or require medical attention please call your doctor or visit your closest hospital.

LINKS. In some instances, clicking on a link may take you to another website. When providing links to other sites, if any, DCDCPC does not guarantee, approve, or endorse the information or products available at these sites or any linked site further contained in a linked site, nor does a link indicated any association with or endorsement by the linked site to this Site.

IP AND TRADE-MARK STATEMENT.The Content is the exclusive property of DCDCPC and are protected by Canadian and international copyright laws. Any unauthorized use of such Content without written permission of DCDCPC is prohibited. SPINEGROUP, SPINEgroup, ADVANCING PATIENT CARE and all other names, titles, logos, and SPINEGROUP designs identifying the goods, services and brands of DCDCPC including any derivative and related names, titles, logos and designs, are trade-marks and the sole property of DCDCPC in Canada and elsewhere. All other names, titles, logos and designs appearing on this website are the property of their respective owners.

GENERAL. These TOU constitute the entire agreement between you and DCDCPC and govern your use of the Site. The TOU and the relationship between you and DCDCPC shall be governed by the laws of the province of Ontario and Canada without regard to its conflict of law provisions. You and DCDCPC agree to submit to the personal and exclusive jurisdiction of the courts located within the province of Ontario, Canada. The failure of DCDCPC to exercise or enforce any right or provision of the TOU shall not constitute a waiver of such right or provision. If any provision of the TOU is found by a court of competent jurisdiction to be invalid, the parties nevertheless agree that the court should endeavour to give effect to the parties’ intentions as reflected in the provision, and the other provisions of the TOU remain in full force and effect. You agree that regardless of any statute or law to the contrary, any claim or cause of action arising out of or related to use of the Site or related to the TOU must be filed within one (1) year after such claim or cause of action arose or be forever barred.