O CONNOR REHAB & WELLNESS CLINIC. Patient Information Record
|
|
- Prosper Sullivan
- 8 years ago
- Views:
Transcription
1 Patient Information Record Date: Patient s Name: Last First MI Address: Street City Province Postal Code Home Phone ( ) Work ( ) Cellular( ) (Please circle best number to reach you during the day) Address: Sex: M F Date of Birth: / / Age: Health Card #: / / DD MM YY Employer: Occupation: How did you learn about The O Connor Clinic? Doctor / Former Patient / Friend / Internet / Yellow Pages /Other Name: Emergency Information Person to Call: Phone: ( ) Relationship: Insurance Information as Applicable Extended Health Care Company: Policy Number: ID Number: Motor Vehicle Insurance Company: Policy Number: WSIB Claim Number: Most insurance companies cover O Connor Rehab & Wellness Clinic services as an approved provider. We will assist you in obtaining reimbursement by providing you with an itemized receipt, which you can send, as is, to your insurance company for reimbursement. Please present your insurance card to the receptionist so that we may assist you with your insurance reimbursement. Your signature below indicates you are financially responsible for all charges incurred. Signature of Patient or Legal Guardian:
2 History of Injury Questionnaire Date: PT RMT DC JORDAN DUFFY HBK, DPT, RPT; MONA IMENPOUR HonBSc, DPT, PTR Devorah Eisenman BHK, RMT; Jessamyn Nitsch RMT; Sandra Lauzon RMT; Janine Viret RMT DR. LEN HERMAN BSc, DC, CCRD Patient Name: Date of Birth: Injured Joint: Right: Left: Date of Injury: Briefly describe the history of your injury: Major Symptoms: Pain / Swelling / Stiffness / Weakness / Instability / Clicking / Numbness Describe your symptoms: What makes the symptoms worse? What makes the symptoms better? Pain (circle): At rest None Severe With Activity None Severe Does the pain wake you up at night? Yes No Swelling at its worst: None Mild Moderate Severe Occupation: Have you had any injury to this area before? Yes No If yes, when? Diagnosis: Treatment given: Surgery (if applicable) Date: Surgeon and Hospital: What activities/sports do you participate in: What activities are you unable to participate in: What are your goals for therapy? 1
3 History of Injury Questionnaire Date: PT RMT DC JORDAN DUFFY HBK, DPT, RPT; MONA IMENPOUR HonBSc, DPT, PTR Devorah Eisenman BHK, RMT; Jessamyn Nitsch RMT; Sandra Lauzon RMT; Janine Viret RMT DR. LEN HERMAN BSc, DC, CCRD Patient Name: Date of Birth: Who is your family doctor or referring physician: Address: Phone Number: What other health care professionals have you seen for this problem? Diagnosis and Treatment given: Have you had any diagnostic images (Xray, MRI, Ultrasound, CT, etc) of this joint? Yes No Results: General Health: Poor / Fair / Average / Good / Excellent Current Medical History: Diabetes Type: Cardiac Disease Cancer High Blood Pressure Low Blood Pressue High Cholesterol Smoker Asthma Depression Seizure Disorder Skin Condition Stroke Weight Loss Recent Cold/Flu Bowel/Bladder Thyroid Metal Implants Headaches Shortness of Breath Arthritis Joint Replacement Alcohol Use Number of drinks/week: Other: Past Medical History (including surgeries, major illnesses): Past Family Medical History (including surgeries, major illnesses): Medications, special dietary habits, & supplements: Allergies: 2
4 Informed Consent to Physiotherapy Treatment & Assessment Doctors of Chiropractic, Physiotherapy, Medical Doctors and those who use manual therapy techniques such as spinal mobilizations are required to advise patients that there are or may be some risk associated with such treatment and assessment. In particular, you should note: a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains/ sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy mobilization/manipulation; b) There are reported cases of stroke associated with visits to medical doctors and physiotherapists. Research and scientific evidence does not establish a cause and effect relationship between physiotherapy treatment and the occurrence of stroke rather, recent studies indicate that patients may be consulting medical doctors and physiotherapists when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occurring in association with upper cervical mobilization/manipulation is extremely remote; c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused by spinal adjustments or other physiotherapy treatment; d) There are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy. Please inform us if you have an allergy to latex or a sensitivity to heat; e) The Health information custodian for your health information is the owner and proprietor of WRI Group, therefore your file in its entirety will be available for at least 10 years from the date of discharge. The documents available in your record are of a multidisciplinary model, and will be available for this time period for all clinicians or therapists that you see during your care plan. f) Please note that there are multiple Physiotherapists available to serve you and they are all noted on your intake forms. I acknowledge I have discussed or have had the opportunity to discuss with my Physiotherapist the nature and purpose of Physiotherapy assessment and treatment in general and my treatment in particular as well as the contents of this consent. I consent to the Physiotherapy assessment and treatment offered or recommended to me by the Physiotherapist. I also consent to treatment delegated by my Physiotherapist from other physiotherapy care providers. I intend this consent to apply to all my present and future Physiotherapy Assessment and Treatment. Dated this day of, 20. Patient Signature (Legal Guardian) Witness Signature Name: Name: Patients Date of Birth: (MM/DD/YY)
5 Informed Consent to Physiotherapy Support Personnel Physiotherapy Support Personnel (Physiotherapy Assistants) are required to obtain informed consent from each patient or his/her substitute decision maker for their involvement in the delivery of the physiotherapy treatment plan. It is required to explain to each patient the relationship between the physiotherapist and the physiotherapist support person for the purposes of clarifying their individual roles and responsibilities in the assessment, reassessment and progression of the physiotherapy treatment plan. The Physiotherapy Assistant will perform usual treatment with respect to the respective care plan for your injury. The Physiotherapy Assistant will not perform assessment, Re-assessment or provide care not outlined in your respective care plan. I acknowledge I have discussed or have had the opportunity to discuss with my Physiotherapist the nature and purpose of the Physiotherapy Assistant s role in treatment in general, and my treatment in particular, as well as the contents of this consent. I consent to treatment delegated by my Physiotherapist to other physiotherapy care providers. I intend this consent to apply to all my present and future Physiotherapy Treatment. Dated this day of, 20. Patient Signature (Legal Guardian) Witness Signature Name: Name: Patients Date of Birth: (DD/MM/YY)
6 Consent to Release Confidential Information DATE: PATIENT NAME: PATIENT ADDRESS: DATE OF BIRTH: (day/month/year): / / I hereby grant the representative of O Connor Rehab & Wellness Clinic permission to release information including reports regarding my current and/or past condition (s) to my general health practitioner/health care practitioner/insurer or Workplace Safety and Insurance Board (if applicable). PATIENT S SIGNATURE
7 Massage Therapy/Physiotherapy/Chiropractic Fee Schedules MASSAGE THERAPY FEE SCHEDULE LENGTH OF TREATMENT FEE 30 MINUTES $ $6.50 HST (total $56.50) 45 MINUTES $ $8.45 HST (total $73.45) 60 MINUTES $ $10.40 HST (total $90.40) 90 MINUTES $ $14.95 HST (total$129.95) CHIROPRACTIC FEE SCHEDULE DESCRIPTION OF SERVICE FEE Initial Examination $ (Includes1 st treatment) Subsequent Treatment $ Re-Evaluation $ X-Ray Reading $ Screening Examination $ PHYSIOTHERAPY FEE SCHEDULE DESCRIPTION OF SERVICE FEE Initial Examination $95.00 Subsequent Treatment $65.00 FEES ARE PAYABLE IN FULL AT THE COMPLETION OF EACH VISIT (Unless Special Arrangements have been made with the Office Manager or Clinic Director) WSIB CASES: Physiotherapy fees are fully covered once approval is received from the WSIB. Fees are paid according to the pre-set WSIB fee schedule and are payable directly to the clinic. The patient is responsible for physiotherapy fees if the WSIB refuses the claim for payment. MOTOR VEHICLE ACCIDENT/PERSONAL INJURY CLAIMS: Physiotherapy and related services are directly billed to 3 rd party payers (Extended Health Carrier, Auto Insurer, Lawyer, etc.) assigned to your case. The patient is directly responsible for physiotherapy fees and related services as a direct result of the motor vehicle accident/personal injury should your claim be denied. PLEASE BE REMINDED THAT THE ABOVE MASSAGE TIMES ALLOW A FEW MINUTES FOR ROOM CHANGE OVER. SEVERAL EXTENDED HEATH PLANS REQUIRE A MEDICAL REFERRAL NOTE TO CLAIM PHYSIOTTHERAPY AND / OR MASSAGE FEES. WE WILL ASSIST YOU TO FIND THIS OUT UPON REQUEST. Patient Name:
Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( )
Patient Information Date: First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone:
More informationPATIENTS REPORT OF ACCIDENT
Today s date: PATIENTS REPORT OF ACCIDENT (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your
More informationOrthopedic 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
More informationOrthopedic 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
More informationPATIENT INSURANCE AUTHORIZATION WORKSHEET
PATIENT INSURANCE AUTHORIZATION WORKSHEET We accept all insurances that have in-network and out-of-network benefits. If you do not have insurance benefits for physical therapy, please call us at 858-457-3545
More informationPATIENT 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
More informationName 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
More informationPersonal 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
More informationPatient 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:
More informationWelcome 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):
More informationPatient 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:
More informationPraxis 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
More informationPraxis 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
More information460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca
Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M
More informationCity: 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
More informationBIRTHDATE - - 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(
More informationPROUGH 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
More informationBOYER 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
More informationBody 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
More informationName: 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):
More informationFunction 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
More informationWelcome! 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
More informationAON 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?
More informationDEL 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 **********************************************************************************
More informationNew 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)
More informationMedical 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
More informationWelcome 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
More informationRIDGE 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
More informationDATE 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.
More informationLAST 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:
More informationPERSONAL INFORMATION
Date: Bruns Chiropractic Clinic EXISTING PATIENT INTAKE FORM (For patients treated within the past 3 years) PERSONAL INFORMATION Name: First MI Last Preferred Name: Gender: M F DOB: / / Age Social Security
More informationPatient 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:
More informationWORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
More informationINFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM
INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM NAME: DATE: 1. PURPOSE AND EXPLANATION OF PROCEDURE I hereby consent to voluntarily engage in an acceptable
More informationDo you have private medical insurance (i.e. Blue Cross, Sun Life, Great West Life)? Yes
PERSONAL INFORMATION: The information in this section has remained unchanged from my last visit with CORE Physiotherapy & Rehabilitation Centre Inc. Last Name: DOB: First Name: Health Card Number: Address:
More informationConsultants in Pain Medicine, P.A.
Consultants in Pain Medicine, P.A. ASSIGNMENT OF BENEFITS Private insurance authorization for assignment of benefits and information release: I, the undersigned, authorize payment of medical benefits to
More informationElectronic Health Records Intake Form
Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last
More informationPATIENT 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
More informationREHAB XCEL, LLC. NEW PATIENT INFORMATION
REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S
More informationHome Phone Work Cell Email
Dr. Jerrid Goebel Licensed Acupuncturist 824 1 st Street Dr. Stuart Johnson Sturgis, South Dakota, 57785 Dr. Al Gunderson Telephone (605) 347-4003 Todays date: Patient s Name Date of Birth age Address
More informationAcknowledgement 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
More informationCHAMBERS MEDICAL GROUP 5108 15th Street East, Suite 205 * Bradenton, FL 34203 * (941) 727-9057 * (941) 727-3981 fax
CHAMBERS MEDICAL GROUP 5108 15th Street East, Suite 205 * Bradenton, FL 34203 * (941) 727-9057 * (941) 727-3981 fax PERSONAL INFORMATION: PLEASE PRINT MISS/MRS/MS/MR: AGE: FIRST MIDDLE MAIDEN LAST DATE
More informationNext 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
More informationJaworski 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
More informationWelcome 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
More informationLast 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
More informationCancellation/No Show Policy
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
More information(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
More informationPATIENT 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
More informationRIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION
RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION Today s date: / / EMAIL: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. SS#: - - Birth date: Sex: [ ]
More informationCarter Physiotherapy, PLLC. Patient Contact Information
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 Email Employer Work Address
More information920 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
More informationThank you for choosing ALTITUDE PHYSICAL THERAPY, a Member of the P3 Network - PT-MD Kinect LLC & Partners in Health Healing Center
Thank you for choosing ALTITUDE PHYSICAL THERAPY, a Member of the P3 Network - PT-MD Kinect LLC & Partners in Health Healing Center Below is some information you may find helpful regarding your benefits
More informationNew Auto Patient Intake Form. Auto Insurance
New Auto Patient Intake Form Name_Date of Birth DateDate of Accident Address City/State Zip Phone _Email Address (for clinic news)_ Gender_Marital Status #Children Occupation Company Name_Work Phone Spouse/Guardian
More informationINTEGRATED 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
More informationWelcome to Chirosports Coogee
PAGE 1 OF 6 Welcome to Chirosports Coogee At Chirosports our goal is to optimise your health and increase your quality of life. Chiropractic is an approach to health and wellbeing that assists the body
More information3 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
More informationX 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
More informationPersonal Training Health Screening Questionnaire
Personal Training Health Screening Questionnaire Personal Information Today s date: Title: Dr. Mr. Mrs. Ms. Name: / Birth date: Last name First name Age: Address: Phone: (home) City: Phone: (work) Province:
More informationNew 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
More informationINTEGRATED 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
More information*2PHT* REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE
*2PHT* 2PHT Page 1 REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE In order for us to fully address all aspects of your problem, the following information is needed. Please take time to complete this form.
More informationAtlantis 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
More informationPRO 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
More informationJAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
More informationInsurance (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:
More informationPATIENT 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
More informationSPINE PATIENT HISTORY FORM
Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ 08534 Bldg. D., Suite 220 Mercerville, NJ 08619 22-1897695 SPINE PATIENT HISTORY FORM Please print
More informationPATIENT 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:
More informationAdvantage 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
More informationCAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
More informationNew Patient Questionnaire
New Patient Questionnaire Name: Date: Age: Date of Birth: Right or Left Handed: Height: Weight Primary Care Doctor: Address and Phone number: Occupation (If working): Current work status (full duty, light
More informationHAND & 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
More informationDENVER 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
More informationTHE PHYSIO CENTRE. Motor Vehicle Accident. Instructions for Completing the Forms in this package
THE PHYSIO CENTRE Motor Vehicle Accident Instructions for Completing the Forms in this package There are 2 forms enclosed in this package which are required for patients under MVA coverage. 1. Agree To
More informationPATIENT INFORMATION. Age: Street address: Email: Primary Phone no.: City: State: ZIP Code: P.O. box: Occupation: Employer: Employer phone no.
(Please Print) Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Birth date: Age: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Sex: M F Street address:
More informationJoint Effort Rehab, LLC New Patient Forms
Patient Information DEMOGRAPHICS Joint Effort Rehab, LLC First Name: MI: Last Name: Sex: M F Home Phone: Work Phone: Cell Phone: SSN: of Birth: Email: Referring Physician: Employer Name: Primary Insurance
More informationWORKER S COMPENSATION HISTORY FORM NAME (Last, First, Middle Initial) Height Weight
341 Magnolia Avenue, Suite 101 28078 Baxter Road, Suite 330 Corona, CA 92879 Murrieta, CA 92563 (951) 735-6060 (951) 735-4510 Fax (951) 677-2157 www.ctoamg.com WORKER S COMPENSATION HISTORY FORM NAME (Last,
More informationPhysical 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
More informationNew 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
More informationPATIENT INTAKE AND CONSENT FORM
PATIENT INTAKE AND CONSENT FORM Attachment B1.003A Attachment M7.005C Internal Use Only: A/C# Name A/C Type Office# First Name Last Name City State Zip Responsible Party City Phone Number Relationship
More informationWorkman 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
More informationCENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork
New Patient Paperwork NAME OF PATIENT ( ) MALE ( ) FEMALE ADDRESS APT CITY STATE ZIP HOME PHONE # CELL PHONE # DATE OF BIRTH AGE SOCIAL SECURITY # MARITAL STATUS E-MAIL ADDERSS OCCUPATION EMPLOYER EMPLOYER
More informationEXCEL PHYSICAL THERAPY, INC.
EXCEL PHYSICAL THERAPY, INC. Medical History Form Name: Date of Birth: Date: Are you employed? YES NO Right Handed Left Handed If NO, last day worked? Do you smoke? YES NO #of packs/day Occupation: Height:
More informationPATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME and THANK YOU for applying as a patient in our clinic. We are a very unique team specializing in researched-based spinal and postural rehabilitation that helps our patients
More informationMVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.
MVA/ PI Registration Form Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. Date: Patient # Patient Name: DOB; Gender: M or F SSN Address: City/State:
More informationWork 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
More informationWilliam 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
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 Workers Compensation Form First Name MI Last Name Sex Date of Birth Social Security
More informationPotomac Valley Chiropractic Personal Injury
Potomac Valley Chiropractic Personal Injury Spiro Theodore, D.C. 12105 Darnestown Road, L8 Gaithersburg MD 20878 Please Complete all applicable fields Date: -------------------------------------------------------DEMOGRAPHICS--------------------------------------------------------------
More informationAdvanced 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 ( )
More informationREHAB 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,
More informationTHINK 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
More informationLast 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
More informationThank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
More informationPatient Intake. Insurance Information
Patient Intake First Name: Last Name: Initial: Home Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email: Social Security #: Birth Date: Age: Sex: Male Female Occupation: Employer s Name:
More informationORTHOPAEDIC SPINE PAIN QUESTIONNAIRE
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE
More informationHands-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
More informationARPwave NeuroTherapy / Physical Therapy 255 Park Avenue, Suite 1000, Worcester, Massachusetts 01609 508-202-9173 / www.bostonarpwave.
Patient Consent to Treat ( ) Physical Therapy ( ) ARPwave Therapy When a patient seeks physical therapy in this office, it is essential for both the staff and the patient to work towards the same objective.
More informationMedical 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.
More informationPatient 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
More information