ARPwave NeuroTherapy / Physical Therapy 255 Park Avenue, Suite 1000, Worcester, Massachusetts /
|
|
|
- Rosaline Kathlyn Parsons
- 8 years ago
- Views:
Transcription
1 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. The therapy has a goal, and it is important that each patient understands both the objective and method that will be used to attain this goal. This will prevent any confusion and disappointment. ARPwave Therapy: ARP (Accelerated Recovery Performance) is a system comprised of proprietary technology and protocols that uses a patented bio-electrical current simultaneously with active range-of-motion and other exercise techniques to significantly speed up the body's natural recuperative ability. Physical Therapy: therapy for the preservation, enhancement, or restoration of movement and physical function impaired or threatened by disability, injury, or disease that utilizes therapeutic exercise, physical modalities (as massage and electrotherapy), assistive devices, and patient education and training. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. We do not offer to cure any disease in particular, and if during the course of a physical therapy examination we encounter non-physical therapy or unusual findings, we will advise you. If you desire advice, diagnosis or treatment of those findings, we will recommend that you seek further services of a health care provider who specializes in that area. I,, have been fully informed about all aspects (Print Name) of my condition and have asked appropriate questions concerning the benefits and risk factors of Physical Therapy. I have been informed regarding all fees and charges for services rendered. I understand that Boston ARP & Sport Performance has a 24-hour cancellation policy. I am subject to a $69 charge for a missed or canceled (in less than 24-hours) appointment. There will be a $69 charge for a missed appointment. (Patient Initials) I am also aware that I will be charged 1.5% on all balances over 30 days. I understand that office visits and all other patient charges are due at the time of service. I understand that I am encouraged to ask any staff member of Boston ARP & Sport Performance about any aspect of my care, at anytime, which I see appropriate. Please remember patients may also experience pain and soreness from time to time during the course of treatment. This is quite normal and your treating practitioner will take precautions to minimize your discomfort. I,, understand that in order to give my injury and or (Print Name) condition the highest probability of success, I will follow all treatment guidelines and exercise programs prescribed by the staff at Boston ARP & Sport Performance. Signature Staff Signature / / Date / / Date Version 10/01/2014
2 Informed Consent for Services I, have been informed of the following: 1. That the process of delivering ARPwave NeuroTherapy and/or ARPwave Loosening may be performed with the ARPwave modality to the shoulders, elbows, wrists, back, hips, knees and ankles. 2. As an addition to ARPwave NeuroTherapy and/or ARPwave Loosening, Supportive Therapies may be applied by the physical therapist or by staff under their direction or supervision, incorporating the use of vibration, electricity, traction, motion, bracing, nutritional advice, manual technique, exercise prescription, heat, or cold; 3. I have been informed on occasion some temporary soreness and/or stiffness may occur; less frequently aggravation of presenting symptoms or initiation of new symptoms; rarely bruising, swelling, irritation at the site of the electrodes; even more rare separation/fracture; and extremely rare, nerve or vascular injury may occur in conjunction with the process of ARPwave NeuroTherapy and/or ARPwave Loosening; 4. The above possible general consequences and possible general complications have been explained to me by the physical therapist. 5. I acknowledge that the physical therapist has made no guarantee of a positive outcome from treatment; 6. I have been afforded ample opportunity for questions and answers; and 7. The above absolute and below recorded relative risks, if any, of the treatment procedures, options, and financial obligations have been explained to me by the physical therapist. I consent to the performance of the diagnostic and therapeutic procedures performed by the physical therapist and or staff under the direction and supervision of the office physical therapist(s) involved in I consent to the performance of other diagnostic and therapeutic procedures in the future that may be deemed reasonable and necessary by the doctor and or staff under the direction and supervision of the office physical therapist(s) involved in my case; Consent to Examine and/or Treat a Minor I hereby request and authorize BostonARP and Sports Performance to perform physical examination, related diagnostic tests and to render treatment and related procedures to. This authorization also extends to all physical therapists and office staff members. As of this date, I have the legal right to select and authorize health care services for the minor child (If applicable) - Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in anyway, I will immediately notify this office. Patient Name:Date: Patient/Responsible Party Signature: Date: Relationship to Patient:
3 Patient Information: Patient Intake Form Last Name: First Name: Sex: Date of Birth: _ SS#: - - Address: _ City: State: Zip Code: Work#: ( ) - Home#: ( ) - Mobile#: ( ) - Marital Status: Single Married Divorced Widowed Domestic Partner Employer s Name: Occupation: Physician s Name: Diagnosis: Injury: Work or Auto related? Allergies or Medical Precautions: Emergency Contact: Phone#: ( ) - Patient s signature: Date Signed: History Name: Date of Birth: Right or Left handed What is your Chief Complaint? Rate your chief complaint in order of severity from worst (5) to least (1) Pain Decreased Motion Swelling/edema Stiffness Loss of function Where is your problem? Indicate on the body chart. Pain xxx: Numbness ooo: Tingling zzz:
4 Indicate the nature of your pain and symptoms: Sharp Dull Piercing Shooting Aching Deep Superficial Tingling Numbness Intermittent Burning Stabbing When and how did this problem begin? What makes your symptoms/ pain worse? What makes your symptoms/ pain lessen? Rate your pain on a visual scale (0-10) 0 no pain 10 excruciating pain: Worst it has been Past 2 to 4 weeks Past 24 hours At this moment Are your symptoms worse in the: Morning Afternoon Evening Inconsistent Are your symptoms: Improving Worse Stable Medical History Has this problem affected your daily life or routine? Briefly describe in what ways. Have you had past similar episodes of this current problem? If yes, were you treated with; (circle disciplines, which apply) Physical Therapy, Acupuncture, M.D. (Meds, TPI s) Massage Therapist, Chiropractor, Pilates, General Exercise, exercise with trainer, Self medicated (Advil), ignored it, other, Did they help to alleviate your symptoms? Have you undergone any special tests for this condition? (X-rays, MRI s, ETC) If yes, do you know the results? Please answer the following questions: Yes No 1) Do the current problems interrupt your sleep? 2) Do your symptoms change with coughing or sneezing? 3) Have you had any recent changes in bowel or bladder function? 4) Do you experience any dizziness or vertigo? 5) Have you had any recent change in your weight or appetite? 6) Do you have any intolerance to hot or cold? 7) Do you have any bruising or bleeding disorders? 8) Have you had any skin changes, such as rashes or discoloration? 9) Have you experienced any changes in your vision, such as blurring, double vision, or decrease in your visual fields?
5 10) Have you had a recent episode of nausea/vomiting? 11) Are you pregnant? 12) Do you have osteoporosis? Date of your last bone scan: 13) Do you have any allergies? 14) Have you noticed any shortness of breath or decrease in exercise tolerance? 15) Do you use any assistive devise? (cane foot orthotics) 16) Do you have high blood pressure? 17) Do you have any cardiac problems? 18) Do you have diabetes? 19) Have you ever had cancer of any sort? 20) Do you have a history of neck or back problems? Any other illness, past injuries I should be aware of? Past surgeries yes, no, give brief details: List the medications you are currently taking (over the counter/prescription): Social History Are you presently working? Yes, No, since: Physical/Emotional demands of present occupation? (High, moderate, minimal) Overall activity level: Sedentary, Light, Moderate, Heavy, Very heavy Sports and Exercise (Type, Frequency, Duration) Use of Tobacco Yes, no. Use of Alcohol Yes, No. Family medical History Does any one in your immediate family (mother, father, siblings) have a history of Diabetes, High Blood Pressure, Cardiac Problems, or Cancer? Please list 3 goals of ARPwave NeuroTherapy or Physical Therapy and time frames: 1) 2) 3) Who can we thank for this referral? Thank You for Your Patience and Valuable Time!!!
6 Health Questionnaire 1. What are your goals: Weight loss Fitness Anti-aging Better quality of Sleep Joint health Mental clarity 2. Are you concerned with the amount of toxins and chemicals in your environment? No Yes 3. Are you concerned about your blood glucose levels? No Yes 4. Are you concerned about your bone density? No Yes 5. Would you like to increase your muscle mass? No Yes 6. Do you feel you get enough nutrition from the food you currently eat? No Yes 7. Do you eat organic produce? No Yes 8. Do you currently get a sound 8 hours sleep per night? No Yes 9. Do you feel alert every morning when you wake up? No Yes 10. Do you have a hard time losing weight? No Yes 11. Do you consume coffee, tea, sugar, candy or similar products to give you a boost during the day? No Yes 12. Do you take vitamins and minerals currently? No Yes List: If you would like to find out how to improve your internal body environment, we are considering offering our patients free lectures. Would you be interested in our contacting you when these lectures are scheduled? No Yes PLEASE PRINT: Name Date
7 PRIVACY NOTICE ACKNOWLEDGEMENT We are very concerned with protecting your privacy, especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a copy of our privacy policies and procedures. We encourage you to read this document carefully, for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have any questions or concerns regarding the use or dissemination of your personal health information, we would be happy to address them. I acknowledge that I have offered a copy of Boston ARPwave & Sport Performance LLC Notice of Privacy Practices for Protected Health Information. Patient Name Printed Date Patient Signature Authorized Provider Rep. Personal Representative Printed Personal Rep. Signature Description of personal representative s authority to act for the patient
8 Informed Consent for ARPwave Treatment ARPwave therapy treatment is completely non-invasive and effective. It can elicit an intense sensation, but contains no significant risk. It is not uncommon for patients to experience more than 25% improvement of symptoms in one session. However, since a Direct electrical Current is used, the following Contraindications must be taken into account. Contraindications: Implanted Defibrillator Yes No (circle) History of Blood Clots Yes No (circle) Pacemaker Yes No (circle) Pregnancy Yes No (circle) Active Cancer Yes No (circle) History of Seizures Yes No (circle) Print Name Signature Date Date: Re: Dx: Participant Acknowledges: While most ARPwave patients are successful in reaching their goals, not all patients will achieve their desired results. Boston ARP & Rehabilitation Services, LLC, does not provide any warranties, representations, promises, or guarantees for the results offered by ARPwave Therapy. I am over 18 years old. I am in good physical condition and I have no disability, impairment, or ailment which makes ARPwave treatment inadvisable. (Defibrillator, pregnancy, see above) I understand the above and consent to treatment. Patient Print Name Signature Date Staff Name Signature Date
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
WORKERS 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,
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 **********************************************************************************
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
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:
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
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
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
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:
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:
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
ORTHOPAEDIC 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
CAMARILLO 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
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):
(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
PATIENT 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
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
SPINE 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
PATIENT 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:
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
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
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(
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
Cancellation/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
Auto Accident Questionnaire
Auto Accident Questionnaire Patient s Name: Date Of Accident: Date: Social History: (please complete the following, check all boxes that apply) Are you: Married Single Divorced Widowed # of Children: #
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
JAMES 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:
Patient Insurance Information
Improving Lives & Performance Dr. Jeff Eidsvig, D.C., TPI- CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093 972-312- 9310 New Patient Information / Change of Information : New Patient Change
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
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
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:
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
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
PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and Reports of any X- rays, MRI or Cat scans. Patient s name:
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 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:
How To Get A Medical Checkup From A Doctor
Welcome to Schoonman Chiropractic. We look forward to providing you the best possible care. Please fill out the following information for our records: Name: Name of Parent (If Minor): Address: Phone Number:
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
Personal Injury Questionnaire
Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer
Carter 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
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):
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
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION Last Name First Name MI Mailing Address City Zip code Home Phone
Welcome 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
CHAMBERS 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
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
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.
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
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?
Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
Patients Signature Date. Guardian or Spouse s Signature who authorize care. Phone#: Relationship Phone#:
Hands On Chiropractic I understand and agree that health and insurance policies are an arrangement between an insurance carrier and my self. Furthermore, I understand Hands On Chiropractic will prepare
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.
Dr. Kenneth A. Giraldo, MD, P.A. Patient Controlled Substance Agreement Informed Consent Form
Dr. Kenneth A. Giraldo, MD, P.A. Patient Controlled Substance Agreement Informed Consent Form The following agreement relates to my use of controlled substance for chronic pain prescribed by Dr. Kenneth
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
Cervical Spine. New Patient Form
Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right
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
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
Patient 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:
New Patient Form Please print clearly
New Patient Form Today s Date: Name: Last First MI Preferred name to be called: Email: Address: Street City State Zip DOB: Age: Sex: SSN#: - - Please check a box for the preferred # to call to confirm
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT
REHAB 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
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
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
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
PERSONAL 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
*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
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
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
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
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
WORKER 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,
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:
Potomac 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--------------------------------------------------------------
AUTO ACCIDENT QUESTIONNAIRE
AUTO ACCIDENT QUESTIONNAIRE Patient s Name Today s of Accident Time of Accident AM PM Location of Accident Were you the: Driver / Passenger (circle one) Were you wearing a seat belt? Yes No With a shoulder
LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B
1 Patient Name In order to properly assess your condition, we must understand how much your BACK/LEG (SCIATIC) PAIN has affected your ability to manage everyday activities. For each item below, please
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
How To Pay For Care At A Clinic
WELCOME TO THE HUMAN PERFORMANCE AND REHABILITATION CENTERS, INC. Welcome to Human Performance and Rehabilitation Centers, Inc. The following information will give you a better understanding of our payment
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
Name. Date of Birth Age Occupation. Chief Complaint Please describe your present complaint(s)
Health History 15404 E Springfield Ave Suite 100 Spokane Valley, WA 99037 509.892-9800 Date / / Name Date of Birth Age Occupation Are you here because of: AUTO ACCIDENT? Y / N WORK INJURY? Y / N Chief
Consultants 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
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
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
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
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
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
Upper Arm. Shoulder Blades R L B R L B WHICH SIDE IS MORE PAINFUL? (CERVICAL PAIN SIDE) RIGHT LEFT EQUAL NOT APPLICABLE (N/A) CERVICAL.
1 NECK PAIN Patient Name In order to properly assess your condition, we must understand how much your NECK/ARM problems has affected your ability to manage everyday activities. For each item below, please
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
INFORMED 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
Informed Consent for Physical Therapy Services
Informed Consent for Physical Therapy Services Physical therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages
***************PATIENT INFORMATION****************
SEP BADY, MD ***************PATIENT INFORMATION**************** TODAYS DATE: / / WHICH DOCTOR ARE YOU SEEING? BADY KURUVILLA LIU OTTEN TRAINOR YEE PATIENT LAST NAME: FIRST: MIDDLE INITIAL: ADDRESS: CITY/STATE:
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
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:
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
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
PATIENTS 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
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 ( )
PERSONAL INJURY CASE HISTORY
Name: Mowry Chiropractic Inc. 240 North Liberty Street, Powell, OH 43065 (614) 436-9070 (p) ~ (614) 436-8803 (f) PERSONAL INJURY CASE HISTORY 1. Circle the severity (0 = No Pain to 10 = Very Severe Pain)
Danita Thomas Heagy, DC, LLC 4425 US 1 South, Suite 109 St Augustine FL 32086-3127 904-797-5100 www.drdanita.com
WELCOME! Thank you for choosing this office to assist you with your health care. Once the exam is complete, I will present my findings and recommendations to you briefly. At the Health Dialogue, we will
O CONNOR REHAB & WELLNESS CLINIC. Patient Information Record
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) E-Mail
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. Auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked?