The purpose of this questionnaire is to obtain information that will help determine whether EXECUTIVE MEDICAL SOLUTIONS is right program to assist you with your recovery process. Completing this form as fully and accurately as possible will speed up the process of assessing your suitability for working with EXECUTIVE MEDICAL SOLUTIONS and assist us in our efforts at generating the right program for you.   

Please be assured that all information you provide will be kept confidential, in accordance with the legal and ethical guidelines of the College of Physicians and Surgeons of Manitoba and relevant provincial legislation. If information is to be shared with a third-party specific consent forms will be completed to ensure your will be made aware of it.  

If you require assistance completing this form, please contact our Intake Specialist at 1-800-497-7352.