Cancellation/No Show Policy
|
|
|
- Martha Ball
- 8 years ago
- Views:
Transcription
1 Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You will be required to pay this prior to your next appointment, unless other arrangements have been made. This fee cannot be billed to your insurance company; therefore you are solely responsible for payment. We have adopted this policy for the following reasons: Consistency is crucial for your success in maintaining results and progress toward achieving established goals. Multiple cancellations in your chart may be considered non-compliance for insurance related visits and may invalidate your claim making reimbursement/ settlement difficult. We try to offer appointment times that are the most convenient for our clients. Any blocked off time could have been available for others to schedule. We staff our center based on number of scheduled appointments. Thank you for taking the time to review our policy. If you have any questions, please feel free to discuss them with your Experience Momentum provider or office staff. Please read agreement and sign and date below I am aware of the cancellation policy and realize that I will be charged $50.00 for all future missed appointments not cancelled 24 hours in advance. Patient or legally authorized signature 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 1 of 5
2 Notice of Privacy Practices This notice applies to the information and records we have about you, your health, and the care and service you receive from Experience Momentum Physical Therapy, Nutrition & Fitness (EM). This Protected Health Information (PHI) may be either created or received by EM and may be in the form of written or electronic records or spoken words, and may include information about your health history, symptoms, examinations, test results, diagnoses, treatments, procedures, related billing activity, and similar types of health-related information. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes us to do so. You may see your record or get more information about it by contacting EM. Our Notice of Privacy Practices can be found posted in the lobby of our main office, which describes in more detail how your health information may be used and disclosed, and how you can access your information. If you have any special requests to how Experience Momentum Inc. shares your information, please contact our Privacy Officer within 24 hours after your initial visit. Blake K. Stephens, DPT, FAFS: By signing below, I acknowledge receipt/review of the Notice of Privacy Practices. Patient or legally authorized signature Consent to contact you regarding the services EM provides and has provided Experience Momentum Physical Therapy, Nutrition, and Fitness is driven to always maintain the standards of the care we provide. By consenting, you are allowing us to contact you during or after your course of care regarding the services you have been provided or about other services we have here at EM for both quality improvement and in-house promotion (only within Experience Momentum Inc.). I, (printed name), give EM permission to contact me regarding the above. Consent to Leave a Message EM works to ensure that confidentiality regarding your medical information and care is maintained at all times. Because of these confidentiality concerns, we need your signature to allow us to leave a message regarding your medical care/procedure with someone in your household, on an answering machine, or voice message. I, (printed name), give EM permission to leave a message regarding my medical care on an answering machine or with an individual at the following numbers. Yes No Home Phone Cellular Other Signature 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 2 of 5
3 General Intake Thank you for choosing Experience Momentum Physical Therapy, Nutrition & Fitness. The more we know about you, the quicker we can help you reach your rehabilitation, health and fitness goals. Please take a moment to answer the following questions. A. Client Information Name of Birth Age Male Female N/A Address City State Zip Day Phone Cellular Phone Emergency Contact Phone Parent/Guardian Name (if under 18 y.o.) Occupation Company Hrs/Wk How did learn about Experience Momentum? (circle one) Friend Self Internet Healthcare Professional Other Check this box to receive our monthly fitness, wellness, and nutrition newsletter via . B. Primary Insurance (if seeking reimbursement) Company Subscriber ID Group # Subscriber s First, MI, Last Name of Birth Relationship to the client is Self Spouse Parent Other C. Secondary Insurance (if applicable) Company Subscriber ID Group # Subscriber s First, MI, Last Name of Birth Relationship to the client is Self Spouse Parent Other As a complimentary service, we will bill your insurance company for you. Once we receive payment from your insurance provider, any patient responsible portions will be billed to you directly. Copays are due at time of service. Note you may be subject to annual deductibles. It is in your best interest to contact your insurance company to verify your benefits for Physical and Massage Therapy. I authorize my insurance benefits to be paid directly to Experience Momentum Inc. I understand I am responsible for any balance due, attorney or collection costs for services rendered not covered by my insurance due to lack of prior authorization or written referral. I authorize the release of medical information required for my claims to be processed. This may include information regarding diagnosis or treatment of HIV, STD s, drug or alcohol use or abuse, mental illness, or psychiatric treatment. Interest or penalties may be charged. I authorize Experience Momentum Inc. to contact the Insurance Commissioner to aid in receiving payment if necessary. Signature (Parent or guardian if under 18) 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 3 of 5
4 Massage Therapy Intake General Symptoms Description Who may we thank for referring you? Describe your current condition: How did the condition begin? When did the condition first present? What makes the condition better? What makes the condition worse? Are you currently or have you previously received any treatment(s) for this condition? Yes No If yes, please explain: Specific symptom(s) description How severe is your pain (circle) No pain Unbearable pain How often are your symptoms present? Describe your current symptoms/ pain (Circle all that apply) Tingling - Numbness - Burning - Soreness - Shooting - Throbbing - Dull/ Achy - Sharp/ Stabbing Can you perform daily activities? (circle) without pain Severe pain How does your current condition influence your quality of sleep (circle) no effect significant effect What goals do you hope to achieve with massage therapy? Symptoms Location Please rate your level of stress (circle) mild Severe Please circle areas of pain, tingling, numbness, burning, soreness or tension Notes: Continue to next page 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 4 of 5
5 Health History Have you had any of the following conditions? Musculo-Skeletal Circulatory/ respiratory Endocrine Bone or Joint disease Tendonitis Bursitis Broken/ Fractured bones Joint dislocation arthritis sprains/strains low back, hip, leg pain neck, shoulder, arm pain Headaches/ head injuries Spasms/ Cramps Joint bone or muscular surgeries Fibromyalgia Skin Allergies rashes Eczema Sensitive skin Heart Condition Varicose veins blood clots high blood pressure low blood pressure lymphedema breathing difficulty asthma sleep apnea Reproductive Pregnant (week) Nursing (weeks postpartum) Severe or unusual PMS Erectile dysfunction Enlarged Prostate Immune/autoimmune Rheumatoid Arthritis Chronic Fatigue Syndrome I understand that clinical massage/bodywork is for the purpose of relaxation, stress reduction, and relief from muscular HIV/Aids tension through manipulation of soft tissue. It is not for the cause of diagnosis or prescription, and it does not replace the need for proper self-care. I understand that while massage therapy may at times be uncomfortable it should not be painful and that it is my responsibility to notify my Massage Therapist if the pressure needs to be decreased. Because massage should not be performed under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions truthfully. I agree to keep my Massage Therapist updated on any changes to my medical profile I confirm that the information I have provided is correct to the best of my knowledge Diabetes (type) Hyperthyroid Hypothyroid Cancer Other Psychological disorder mental disability Bipolar/ Depression Drug/ Alcohol addiction Epilepsy Seizure Parkinson s disease Current Medications: Patient Name: Patient Signature: _ : 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 5 of 5
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with
Medical History Questionnaire
Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of
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
1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
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
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
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):
New Patient Evaluation
What area hurts you the most? (Please choose one) When did this pain start? Neck Other: Back How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes
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:
Grey Physical Therapy and Sports Medicine Center
Grey Physical Therapy and Sports Medicine Center 101 Phoenix Ave, 2D Body Made Better by Grey A Tradition of Caring Since 1984 Enfield, CT 06082 Ph (860) 741-2541 F (860) 745-5264 Patient Information First
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
Therapeutic Massage .(W). Chiropractor
Therapeutic Massage Please take a moment to answer the following questions. The information you provide will be used to customize your session to your needs and exclude any techniques that may be medically
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):
REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,
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?
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:
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:
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
Function First Physical Therapy, P.C. Patient Intake Form
Patient Intake Form Patient Information: Last Name: First Name: Sex: Date of Birth: SS#: - - Address: City: State: Zip Code: Work#: ( ) - Home#: ( ) - Email: Mobile#: ( ) - Marital Status: Single Married
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
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
MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
Insurance (Let us make a copy of your insurance card and you can skip this section)
Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:
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 INTAKE FORM Pennsylvania Chiropractic and Rehab, LLC Dr. Jason Cozart. OOB Age _
PATIENT INTAKE FORM Pennsylvania Chiropractic and Rehab, LLC Dr. Jason Cozart Patient Name: Date: OOB Age Address City, State, Zip Home Phone Work Phone Other em ail address M or F Marital --~------- Status
Primary Policy Holder Same as Patient Relationship to Patient: Name: Address: Apt# City: Patient Information. Name: Address: Apt# City: State: Zip:
Patient Information Name: Address: Apt# City: State: Zip: Sex: MALE FEMALE of Birth: Cell Phone: Home Phone: Work Phone: Email Address: Employer: Employer Phone #: Employer Address: Social Security #:
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
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
Workman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
NORTHERN EDGE PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including
HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)
HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
Integrative Therapies
Hello! And welcome to Integrative Therapies! Integrative Therapies 7E Oak Branch Drive Greensboro, NC 27407 www.integrativetherapies.net 336-294- 0910 We are very happy that you have chosen to partner
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
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 **********************************************************************************
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
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:
PATIENT INTAKE INFORMATION
PATIENT INTAKE INFORMATION Patient Intake and Worker Compensation / Insurance Information Please have insurance card(s) available for copying Family Physician: Please fill in ALL blanks unless specified
Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:
Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out
EZ REHAB SOLUTIONS: Patient Intake Information
EZ REHAB SOLUTIONS: Patient Intake Information PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: : / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home
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 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
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
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
Next Level Physical Therapy PC Patient Information
Next Level Physical Therapy PC Patient Information First Name M.I. Last Name Date of Birth SS# (if minor, leave blank) Student? F/T P/T NO Street Address Billing Address (if different) City State Zip Home
Atlantis Physical Therapy Associates
Atlantis Physical Therapy Associates Date Called/Walk-In: Appointment Date: Time: PT/OT: Diagnosis/ICD9/Body Parts: Frequency & Duration: X Referring Doctor: Dr. Phone#: Fax: NPI: Addresss: Ins Type: (Circle
New England Pain Management Consultants At New England Baptist Hospital
New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants
(STREET) (CITY) (STATE) (ZIP) DOB: / / Soc. Sec # : - - Employer Address: (STREET) (CITY) (STATE) (ZIP)
PATIENT INFO Name: Address: (LAST) (MI) (FIRST) (STREET) (CITY) (STATE) (ZIP) Home Phone: Work Phone: Cell Phone: Email Address: DOB: / / Soc. Sec # : - - Driver s License #: State: Marital Status: S M
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
New Patient Registration Information
New Patient Registration Information Form 8026 5/09 3038 PR&C Dear WellSpan Orthopedics Patient: Welcome to WellSpan Orthopedics. Thank you for allowing us the opportunity to assist with your health care
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 Portland Family Health!
4004 SE Woodstock Boulevard Portland, Oregon 97202 Phone: (503)777-0444 Fax: (503)777-0445 info@portlandfamilyhealth.com www.portlandfamilyhealth.com Welcome to Portland Family Health! We are honored that
Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
Creekside Physical Therapy and Rehabilitation
Creekside Physical Therapy and Rehabilitation PATIENT INFORMATION Patient s Name: Social Security #: Age: Sex: M/ F Date of Birth: Email: Home Address: City: State: Zip: Telephone (Hm): Work: Mobile: Employer:
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
Patient Name: Patient Signature:
HIPAA PRIVACY POLICY 3518 Riverside Dr. Suite 104, Upper Arlington, OH 43221 Name: Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how
MONTESANO PHYSICAL THERAPY, INC. Patient Intake Information
MONTESANO PHYSICAL THERAPY, INC. Patient Intake Information PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: : / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S.
WELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
Physical Therapy Services Medical History Form
Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently
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(
Hands-On Care Physical Therapy P.C PhysioCare Physical Therapy P.C EXPLANATION OF PROCEDURES
EXPLANATION OF PROCEDURES Welcome to our practice. You are here because you have been referred to us by your doctor for Physical Therapy. Physical Therapy is defined as: The evaluation, treatment or prevention
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
Personal Health Insurance Add family member
Personal Health Insurance Add family member Policy 037000 ID number of owner A Plan information Health Coverage Choice (HCC) plan - Only complete section A, B and D. Add my spouse and/or child. I am aware
MVA New Patient Paperwork
Please Complete Entire Form MVA New Patient Paperwork Patient Name: M F Today s Date / / Address: Employer: _ City, State, Zip: Address: Home Phone: ( ) City, State, Zip: Cell Phone: ( ) Work Phone: (
Medical Massage Client Intake Form Medical Massage Client Intake Form
Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you.
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( )
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -
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
PATIENT /GUARDIAN SIGNATURE
PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
PATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
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
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
Work Injury Information Continued
Welcomes You Full Name: Today s Date: DOB: M / F Social Security #: DL# Address: City: State: Zip Code: Home # : Cell #: Occupation: Employer: Employer Address: Employer Phone: Employer Fax: Emergency
Arrive 15 minutes before your scheduled appointment time.
Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
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
DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION
DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single
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
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
BOYER CHIROPRACTIC INC
Patient Name: Birthdate: Sex: M / F Address: City: State: Zip: Telephone: Social Security #: Driver Lic. #: Occupation: Employer: Work Phone: Address: City: State: Zip: Subscriber Name: Health Plan: Subscriber
(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _
2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or
OUTPATIENT REHABILITATION CENTER
OUTPATIENT REHABILITATION CENTER 2131 K STREET NW, SUITE 620 WASHINGTON, DC 20037 OFFICE #: 202-715-5655 FAX #: 202-715-5664 Welcome to the George Washington University Hospital Outpatient Rehabilitation
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:
Orthopaedic Institute of Ohio Demographic Information Date:
Orthopaedic Institute of Ohio Demographic Information Date: Patient Name Home Phone Cell Phone Employer Phone Mailing Address (include PO Box and Apt. #) Family Doctor Name and Phone Number City, State,
CHIEF COMPLAINT (No, you can't just say your "husband" or "wife")
Date: / / Patient s Full Name: Home Phone: Cell Phone: E-Mail: Male Female Age: Date of Birth: / / Social Security #: - - Address: City: State: Zip: How would you like to be addressed by our staff? Married
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
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)
Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
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
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
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
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
3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:
Eaton Chiropractic & Rehab Center 1 Patient Information Name: First Initial Last Address: Home: Work: Cell: DOB: Male Sex: Female SSN: Email: Single Divorced Marital Status: Married Separated Widowed Full
*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
WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?
Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address
IMS Allergy & Immunology New Patient Registration Sheet. Personal Information
Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
Welcome to Central Florida Foot and Ankle Center
Welcome to Central Florida Foot and Ankle Center PATIENT INFORMATION Patient Name Address City State Zip Mailing Address City State Zip SS# DL# E-Mail Sex M F Age Birth Married Widowed Single Minor Separated