Carter Physiotherapy, PLLC. Patient Contact Information
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1 Carter Physiotherapy, PLLC Patient Contact Information Patient Name Today s Date Address City State Zip Code DOB Gender Marital Status Occupation Home Phone Work Cell Other Fax Employer Work Address City State Parent/Guardian/Spouse Name Address City State Occupation Employer Work Phone Cell Phone Contact Phone Emergency Information/ Nearest Relative Name Relationship Address City State Zip Code Home Phone Work Cell Phone Responsible Party Information Name Relationship Address City State ZipCode SS# Contact Phone I/We authorize Carter Physiotherapy, PLLC to release all medical information and/or records to my requesting insurance company and/or referring physician. Signature of Patient/Guardian Date
2 Carter Physiotherapy, PLLC. Patient Questionnaire (This information is kept confidential) Name Today s Date Gender Age DOB Physician From whom did you hear about us? History of current condition Any special tests that have been performed, the body part tested, and the results: (ie: X-ray, MRI, Cat Scan) Have you had any other treatments for your current condition? (ie: PT, Chiropractic, Massage, Acupuncture) Please list practitioners. What has had a positive effect? What has had a negative effect? Have you been advised to have any surgery that has not been done? Please list all previous injuries, accidents, and any other pertinent medical information
3 Please list all medical conditions and/or health concerns Please list all current medications: Please list all allergies: Any previous surgeries? (please note year) Do you now have or have you had any of these symptoms in the past year? (check all that apply) Change in bowel movements Persistent joint pain Irritable bowel Blood in bowel/urine Hot flashes Vertigo or dizziness Persistent nose bleeds Difficulty concentrating Learning disabilities Tiredness/fatigue Muscle spasms Fainting spells Eating disorder/difficulty Difficulty Sleeping Other Any history of: (check all that apply) Head or spinal injuries Recurrent headaches Meningitis Stomach ulcers Heartburn/indigestion Shortness of breath Anemia Asthma Bladder infection Heart Problems Depression Other Dental History: (please elaborate when possible) Who is your dentist? Ever wear braces? Ever wear a retainer? Grind or Clench your teeth? Ever wear dental splint? Currently using a night guard? History of TMJ disorder? Popping or clicking in jaw? Jaw ever lock up? Other:
4 Please describe your own birth (forceps, natural, C-section) Have you ever been knocked unconscious? concussions? Head/spinal injuries? FOR WOMEN ONLY: Please list number of: pregnancies children Date of last pelvic exam Date of last pap smear test: negative or positive Please check all that apply: Menstrual cycle irregular Pass blood clots Pain and cramping during period Pain with intercourse Take birth control? How long? Any other information about pregnancies, complications with delivery, menstrual problems?
5 OFFICE POLICIES & PROCEDURES Carter Physiotherapy, PLLC Welcome and thank you for choosing Carter Physiotherapy for your Physical Therapy needs. Texas Law and the State of Texas Physical Therapy Board requires patients to have a written Referral from a licensed medical person (MD, DO, DC, DDS, DPM, ANP, PA). It is your responsibility to obtain and maintain a current referral prior to evaluation and during your treatments. As a courtesy to others and our Therapists and to other patients trying to get scheduled, we require a 24-hour (or greater) notice for cancellations. This allows others on waiting lists to be seen. Only emergencies or illnesses are excusable. A $75 fee will be billed upon violation of this policy. PAYMENT/BILLING POLICIES Carter Physiotherapy is a fee-for-service clinic. This means that payment is due at the time services are rendered and we will Not bill your insurance company. We can, upon request, provide receipts with diagnosis and treatment codes which you may choose submit to your insurance company. If further reports or documentation are requested, these will be provided. We accept cash, personal checks, and credit cards. Medicare will Not pay for services rendered at Carter Physiotherapy. Medicare does not pay for all of your health care costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor, healthcare provider, or fitness professional has recommended it. Right now, in your case, Medicare will not pay for our services as we are not a Participating Provider with Medicare or any other insurance company, and we only agree to work with Medicare clients for fitness, prevention, and wellness goals (which are not covered services under Medicare). You will not be able to submit for reimbursement as our services do not meet the rules set by Medicare regulations. Therefore, any receipts you may request will not include diagnosis codes and other information that Medicare claims usually posses. Signing below means that you have received and understand this notice. You may receive a copy upon request at any time. Given you will be paying at the time of services, if your insurance company reimburses our clinic, these monies will be returned to them and a new check must be cut to you personally. We are available for after hours, weekend, and home visits at additional costs. Supplies and additional items are also at additional costs. Please clarify prior to your first treatment if you have any questions regarding charges or fees.
6 PRIVACY POLICY I understand that Carter Physiotherapy, PLLC will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. CONSENT TO TREATMENT Carter Physiotherapy is a hands-on Physical Therapy clinic. Though highly specialized, treatment consists primarily of manual therapy techniques and treatment forms that are published or otherwise publicly known. Forms of ultrasound, electrical stimulation, traction, deep tissue massage, therapeutic exercise programs, gait training, neuromuscular re-education, craniosacral therapy, myofascial release, bone and soft tissue manipulation, as well as other treatment modalities may be used. Some of the hands-on treatment techniques require deep pressure which may cause bruising and periods of increased soreness which may last from 1-72 hours. Symptoms may also change and move to other parts of the body. This is not unusual and is rarely a concern, however, please ask if you have any concerns or questions. The number of treatments needed and recovery time can vary due to the age of injury, number of times injured, age of patient and many other contributing factors. I have read and fully understand the above statements. I understand the nature of the treatments at Carter Physiotherapy, PLLC. I authorize Jarod Carter PT, DPT and the fully trained staff to use treatment techniques as deemed necessary for my safe and effective recovery. I have read and completely understand the above written statements. X Date Signature of patient/legal guardian I also understand that Medicare will not reimburse for services rendered by Carter Physiotherapy, PLLC. X Date Signature of patient
7 Carter Physiotherapy, PLLC. Photograph & Video Release Form Video recordings of our treatments help us get the word out about what we do and how we can help others. They also help us to teach others how to replicate our methods and better help their patients. With that said, please read below and let us know if you d be okay with us recording and using any part of your treatment sessions. I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. Photographic, audio or video recordings may be used for the following purposes: conference presentations educational presentations or courses informational presentations on-line educational courses educational videos for-profit endeavors By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only. By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes. Full Name Signature Date If this release is obtained from a presenter under the age of 18, then the signature of that presenter s parent or legal guardian is also required. Parent s Signature Date
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