Houston Healthcare Therapy Agreement
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- Flora Parrish
- 8 years ago
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1 Houston Healthcare Therapy Agreement We will do our best to: Begin all sessions on time Explain your treatment program and progress to you Accommodate your schedule Be consistent with your therapist and assistant Reschedule if you must miss an appointment We ask you to: Arrive on time for all sessions Participate in setting your therapy goals Call at least 24 hours ahead of time if you need to cancel an appointment (pain is not a reason to cancel a session) Follow recommended home activities and exercise programs Dress appropriately for your therapy (wind suits, walking shorts and sweat pants are recommended) Our department guidelines are as follows: Three cancellations without notice will be automatic grounds for discontinuation of services Every effort will be made to keep you with the same therapist/assistant; however, there may be circumstances when another therapist will need to provide your treatment Every effort will be made to give you your preferred appointment time as the schedule allows All co-pays are due at time of service The goal of our staff is to provide excellent service and care for each patient on an individual basis. We will assist you in every way to achieve a positive outcome. If you have any questions please feel free to speak with your therapist. Name: DOB: Client signature: Date: Staff signature: Date: Pavilion Rehab Houston Lake Rehab 233 North Houston Road, Suite B 2510 Highway 127 Warner Robins, Georgia Kathleen, Georgia
2 Registration Form NAME DOB AGE SEX MARITAL STATUS TELEPHONE - - PATIENTS SS# - - CELL PHONE - - ADDRESS CITY STATE ZIP CODE COUNTY REFERRING PHYSICIAN PRIMARY PHYSICIAN EMPLOYER EMPLOYER PHONE EMPLOYER ADDRESS CITY STATE IF RETIRED, GIVE DATE SPOUSE RETIRE DATE GUARANTOR INFORMATION IF PATIENT IS A MINOR NAME OF PARENT OR GUARDIAN RELATIONSHIP ADDRESS PHONE - - EMERGENCY CONTACT INFORMATION NAME PHONE - - ADDRESS CELL PHONE - - RELATIONSHIP TO PATIENT NEAREST RELATIVE PHONE - - ADDRESS RELATIONSHIP 2
3 INSURANCE INFORMATION PRIMARY INSURANCE POLICY # INSURANCE PHONE - - ADDRESS SUBSCRIBER NAME GROUP # (If different from patient) ADDRESS CITY STATE ZIP DATE OF BIRTH SS# RACE SEX MARITAL STATUS IF RETIRED, GIVE DATE SPOUSE RETIRE DATE SECONDARY INSURANCE POLICY# INSURANCE PHONE - - ADDRESS SUBSCRIBER NAME GROUP # (If different from patient) ADDRESS CITY STATE ZIP DATE OF BIRTH SS# RACE SEX MARITAL STATUS ADDITIONAL INSURANCE INFORMATION *WORKER S COMPENSATION EMPLOYER CLAIM # MAILING ADDRESS CONTACT NAME PHONE - - *AUTOMOBILE LIABILITY DATE OF INJURY NAME OF INSURED PHONE - - INSURED S ADDRESS RELATIONSHIP INSURANCE COMPANY PHONE - - CLAIM # CONTACT 3
4 GENERAL MEDICAL HISTORY NAME INJURY DATE PROBLEM AREA ARE YOU CURRENTLY WORKING? Y N TYPE OF WORK REGULAR DUTY LIGHT DUTY MEDICAL LEAVE HAND DOMINANCE RIGHT LEFT PLEASE CHECK IF YOU HAVE BEEN TREATED FOR: ( ) HEART ATTACK ( ) KIDNEY DISEASE ( ) PACEMAKER ( ) ANY INFECTIOUS DISEASE: (TB, AIDS, ( ) HERNIAS HEPATITIS) ( ) HIGH BLOOD PRESSURE ( ) DIABETES ( ) LUNG DISEASE/PROBLEMS ( ) METAL IMPLANT/JOINT REPLACEMENT ( ) HEAD TRAUMA/CONCUSSION ( ) PSYCHIATRIC/EMOTIONAL PROBLEMS ( ) STROKE ( ) ARE YOU PREGNANT? ( ) DIZZINESS/BALANCE PROBLEMS ( ) ALLERGIES: (LATEX, MEDICATION, FOOD) ( ) TOBACCO USAGE ( ) BACK/NECK INJURIES ( ) CANCER ( ) ARTHRITIS ( ) GASTROINTESTINAL PROBLEMS ( ) FRACTURES ( ) JOINT DISLOCATION LIST CURRENT MEDICATIONS HAVE YOU RECENTLY HAD AN X-RAY, MRI, AND/OR CT SCAN FOR YOUR CONDITION? FINDINGS DATE PLEASE LIST ANY MAJOR SURGERY/HOSPITALIZATIONS WITHIN THE PAST FIVE YEARS: REASON DATE REASON DATE HAVE YOU EVER BEEN EVALUATED AND/OR TREATED BY ANY OTHER PHYSICAL THERAPIST, OCCUPATIONAL THERAPIST, CHIROPRACTOR, OR HEALTH CARE PRACTITIONER FOR THIS CONDITION?
5 Rehab Outcomes Intake Patient Name: DOB Date Pain On a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain, place an X on the scale below to rate your current level of pain. No Mild Moderate Severe Extremely Pain Pain Pain Pain Severe Pain Motion On a scale of 0 to 10, with 0 showing no limitations in your ability to move and 10 being unable to, place and X on the scale below for your current level of motion (bending over, reaching overhead, twisting your trunk, etc.) No Minimal Moderate Severe Unable Limitation Limitation Limitation Limitation to Perform Function On a scale of 0 to 10, with 0 being able to perform your entire normal daily activities, and 10 being that you are unable to perform any of your normal daily activities, place an X on the scale below for your current ability to perform your normal daily activities. No Minimal Moderate Severe Unable Limitation Limitation Limitation Limitation to Perform Insurance: Zip Code: MD: 5
6 PAVILION REHAB HOUSTON LAKE REHAB 233 North Houston Road, Suite B 2510 Highway 127 Warner Robins, Georgia Kathleen, Georgia As a courtesy, we try to verify your therapy benefits prior to your first visit. However, it is your responsibility to inform us if referrals or limitations are required by your policy. If you wish your claims to be filed to another insurance company other than your group health insurance, you must provide the necessary information. Signature: Date: 6
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
New Patient Registration Information
New Patient Registration Information ADAMS COUNTY LOCATIONS YORK COUNTY LOCATIONS Adams Health Center........ (717) 339-2620 Apple Hill................ (717) 741-8240 Aspers Health Center........ (717)
Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
AON Physical Therapy & Wellness
AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
Dear Patient: Photo ID Insurance card(s) Prescription/referral for physical therapy Any Claim documentation (auto/w/c)
7500 Hanover Pkwy Ste. 103 Greenbelt, MD 20770 Phone: 301.446.1644 Fax: 301.446.1647 6510 Kenilworth Ave. Ste. 1100 Riverdale MD 20737 Phone: 240.770.8750 Fax: 240.770.8156 Dear Patient: Attached is your
X Guarantor/Parent/Guardian Signature
Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency
Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
Welcome to Back Country Physical Therapy, Intake Form
Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):
Personal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
DEL MAR PHYSICAL THERAPY Patient Information
PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) Email **********************************************************************************
920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com
920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com Thank you for selecting Timberline to be a part of your rehabilitation. Below we have condensed
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medicare Insurance Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning
Orthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
*WELCOME TO OUR OFFICE*
*WELCOME TO OUR OFFICE* WE FIND THAT COMMUNICATION WITH OUR PATIENTS REGARDING OUR BUISNESS OFFICE POLICIES ASSISTS US IN PROVIDING YOU THE BEST SERVICE. THEREFORE WE HAVE PROVIDED A HIGHLIGHT OF SOME
THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!
THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! Please complete and sign all of the enclosed forms. Bring these forms, your physician s referral if required and any other documents required
INTEGRATED PHYSICAL THERAPY a whole- istic approach to physical therapy
Patient s Name: D.O.B.: Age: Address: City: State: _ Zip Code: Home Phone #: Cell #: _ Business #:_ Social Security Number: E- mail Address: Referring Physician? _ How do you hear about us: Dr. Referral
BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )
PATIENT INFORMATION SOCIAL SECURITY # MARRIED SINGLE WIDOW DIVORCED NAME Last First MI HOME ADDRESS BILLING ADDRESS ACCT# DRIVER S LICENSE# BIRTHDATE - - AGE SEX CITY STATE ZIP CITY STATE ZIP PHONE HOME(
DOB: // // Gender: Male Female. Home: Cell: Work:
Core Physical Therapy Clinics, LLC Paper Registration Form Patient Name Date DOB: // // Gender: Male Female Address: City State: Zip Code Home: Cell: Work: Email: Emergency Contact Employer: Name Insurance
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp
Orthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Jaworski Physical Therapy, Inc. Private Health Insurance. Worker s Compensation (complete the following)
Jaworski Physical Therapy, Inc. Patient Name: Date: Private Health Insurance Name of Private Health Insurance: ID#: Group#: Cardholder Name: Cardholder Date of Birth: Relationship to Patient: Phone: Address
Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.
Dear Patient, Thank you for choosing San Antonio Center for Physical Therapy for your rehabilitation needs. We want your time with us to be a positive experience, one that leads you down a road of successful
Welcome to Tri-State Rehab Services
Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely
PATIENT REGISTRATION
Orthopedic & Sports Therapy Center PATIENT REGISTRATION NAME DATE OF BIRTH SSN# FIRST MI LAST PHONE INFO: HOME BEST WAY TO CONFIRM APPOINTMENTS WORK CALL TEXT EMAIL MOBILE (TEXT) MOBILE CARRIER EMAIL ADDRESS
RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
PATIENT REGISTRATION
PATIENT REGISTRATION NAME: HOME ADDRESS: CITY, STATE, & ZIP CODE: HOME PHONE: CELL: WORK: SOCIAL SECURITY NUMBER: SEX: MALE/FEMALE DATE OF BIRTH: AGE: EMERGENCY CONTACT: RELATIONSHIP: EMERGENCY CONTACT
PATIENT INFORMATION FORM
737 Pearl Street, Suite 108 Phone: 858.456.2114 Fax: 858.456.2103 www.abilityrehabsd.com PATIENT INFORMATION FORM Please print and complete ALL items. If an item doesn t apply, put N/A Patient Name: Age:
Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our facility.
AVIDAPT 1391 Dublin Rd, Columbus, OH 43215 614-487-9715 avidapt.com Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
How To Get A Physical Therapy At West Point Physical Therapy Center
Palmdale (Main) 1115 West Ave. M-14 Palmdale, CA 93551 (661)265-0060 To our workers compensation patients: Cathedral City 68-845 Perez Rd., Ste. H6-H7 Cathedral City, Ca 92234 (760)328-0292 California
þ Bring your completed forms with you. þ Arrive 10 to 15 minutes early the first day.
BRIAN T. WILLIAMS M.S., P.T. KELLY GAMMAGE P.T. CHRISTOPHER OLIVEIRA P.T. SARA G. RIEDEL P.T., C.S.C.S. ORTHOPEDIC SPORTS PHYSICAL THERAPY EVALUATION & TREATMENT 155 HILL STREET MILFORD CT 06460 WWW.CENTERREHAB.COM
PACIFIC PHYSICAL THERAPY 14650 Aviation Blvd., Suite 200 Manhattan Beach, CA 90250. Referring Doctor: PLEASE PRINT CLEARLY Email Address:
PACIFIC PHYSICAL THERAPY 14650 Aviation Blvd., Suite 200 Manhattan Beach, CA 90250 Date: Referring Doctor: PLEASE PRINT CLEARLY First Name: Last Name: Height: Address: City, St., Zip:_ Email Address: _
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)
Advantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
PRO SPORTS THERAPY, INC. (P.S.T.)
Dear Patient, Thank you for choosing Pro Sports Therapy. Enclosed is the paperwork that you will need to complete and bring with you for your physical therapy evaluation. Please arrive at least 15 minutes
Medical History Questionnaire
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INTEGRATED PHYSICAL THERAPY A Holistic Approach to Physical Therapy
Patient s Name: D.O.B.: Age: Address: City: State: Zip Code: Home Phone #: Cell #: Business #: Social Security Number: E-mail Address: Height: Weight: Referring Physician? Status: Married/Single/Other/Full
ADMISSION FORM PERSON WHO SIGNS CONSENT AND IS RESPONSIBLE FOR BILL. Primary Insurance: Phone: Friend/Relative? Who? Physician: Insurance:
ADMISSION FORM An Affiliate of DENVER PHYSICAL THERAPY PATIENT INFORMATION Patient Name: Address: Home Ph#: Work Ph#: Email Address: Employer Name: Employer Address: Date Injured: SS#: Marital Status:
RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION
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REHAB XCEL, LLC. NEW PATIENT INFORMATION
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Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470
PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone
Patient Information: In Case of Emergency: Physician: Insurance:
For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:
North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
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PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM
Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If
City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work
LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH
PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP E-MAIL HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS:
Guardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.
VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions
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Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you!
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Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
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HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C.
Consent for Care and Treatment I, the undersigned, do hereby agree and give my consent for HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C., to provide Care and Treatment to considered necessary
Patient/Guardian Signature Witness Signature
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Function First Physical Therapy, P.C. Patient Intake Form
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Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO 80218 303-388-0976 www.elevationfoot.com
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Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
PERSONAL INFORMATION
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Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical
Grey Physical Therapy and Sports Medicine Center
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11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
Orthopaedic Institute of Ohio Demographic Information Date:
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1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
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Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
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CORONADO EYE ASSOCIATES GLENN B. COOK, M.D., PhD 801 ORANGE AVENUE, STE. 204 - CORONADO, CA 92118 619.437-4406 FAX 619.522-7983
Dear Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible. Enclosed is your patient information sheet and medical history questionnaire. Please
Welcome! We look forward to serving YOU. If we can do anything to make your time with us more enjoyable, please let us know.
Welcome! We want to thank you for allowing us the opportunity to provide you with the highest level of quality rehabilitation services possible. We are committed to providing you with a comfortable, friendly
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PATIENT REGISTRATION FORM
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IMS Allergy & Immunology New Patient Registration Sheet. Personal Information
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William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737
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Specializing in back and neck pain, sports medicine, and joint injuries
www.rehabissaquah.com 425-394-1200 Fax 425-394-0100 1495 NW Gilman Blvd Ste 4 Issaquah, WA 98027 Dear New Patient: We look forward to meeting you and assisting with your medical care. In order to provide
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LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527 Patient Information Name First Middle Last Address City State Zip Phone Other Contact Email Social Security # DOB
RETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number:
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HEALTH INSURANCE INFORMATION (Please provide copies of all insurance cards) PRIMARY INSURANCE POLICY # GROUP # PHONE #
PATIENT INFORMATION LAST NAME FIRST NAME MI (PLEASE PRINT) ADDRESS CITY STATE ZIP CODE HOME # CELL # WORK # DATE OF BIRTH SEX SOCIAL SECURITY # MARTIAL STAUS REFERING PHYSICIAN/ PRIMARY CARE PHYSICIAN
Hand & Orthopedic Physical Therapy Associates, P.C.
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Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
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How To Get A Medical Checkup
NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate
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Atlantis Physical Therapy Associates
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Dear Patients and Prospective Patients:
www.cheverlychiropracticcare.com CheverlyChiroCare@yahoo.com Dr. Ella Pantazis 12200 Annapolis Rd #221 GlennDale MD 20769 301 464 5813 Fax: 301 464 5815 Dear Patients and Prospective Patients: Our office
New York Ophthalmology, P.C.
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Physical Rehabilitation Center Outpatient Therapy Medical History Goals and Consent for Treatment
Goals and Consent for Treatment The Physical Rehabilitation Department is here to provide you with the highest quality of care. We treat every patient fairly and with respect, and make sure to protect
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER
Integrative Therapies
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Next Level Physical Therapy PC Patient Information
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PATIENT /GUARDIAN SIGNATURE
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Insurance card Picture ID MRI/X-ray reports Therapy referral from referring physician Insurance referral if required from your insurance carrier
Welcome to the Rehabilitation Center of Southern Maryland. Thank you for giving us the opportunity to care for your Physical/Occupational therapy needs. We look forward to helping you in every way we can.