LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH
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- Roland Waters
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1 PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS: S / M / D / W EMERGENCY CONTACT (Name) ONE_ RELATIONSHIP INSURANCE INFORMATION RESPONSIBLE PARTY (If under 19 years) ADDRESS APT CITY STATE ZIP P R I M A R Y I N S UR AN CE COV ER AGE INSURANCE COMPANY SUBSCRIBER NAME SS# DATE OF BIRTH RELATIONSHIP TO PATIENT POLICY ID# GROUP # S ECON DAR Y I N S UR AN CE COV ER AGE INSURANCE COMPANY SUBSCRIBER NAME SS# DATE OF BIRTH RELATIONSHIP TO PATIENT POLICY ID# GROUP # Assignment of insurance benefits, release of information and authorization for treatment, responsibility for payment, and medical release: I authorize PT Solutions to provide physical therapy treatment, tests and procedures considered advisable by my physician. I, the undersigned, do hereby expressly guarantee payment in full of any and all claims and charges in consideration for medical services rendered by PT Solutions. I hereby authorize and demand the assignment of my basic medical, major medical, auto medical, third party medical or any other medical benefits that my apply, herein specified and otherwise payable to me, directly to PT Solutions. I authorize PT Solutions to release medical information acquired in the course of my treatment and examination to my insurance company and to my physicians. If for any reason the account should become delinquent, I agree to pay all rebilling charges, costs related to collection efforts, and reasonable legal fees. I have read and understand the policies as mentioned above. SIGNATURE OF PATIENT, GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE SIGNED Pt Info Revised 11/10/04, 10/22/08, 7/10/12
2 CURRENT INJURY / DISORDER INFORMATION REFERRING DOCTOR: TYPE OF INJURY/DISORDER/CONCERN IS THIS INJURY RELATED TO: WORK / AUTO / SCHOOL SPORTS / RECREATIONAL SPORTS / OTHER PLEASE DESCRIBE HOW AND WHEN INJURY/DISORDER OCCURRED PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PAIN/SYMPTOMS: MY PAIN IS WORSE IN THE: MORNING / EVENING / SAME / FLUCTUATES / IN CONSTANT PAIN PLEASE LIST ANY ACTIVITIES THAT INCREASE YOUR PAIN/SYMPTOMS: PLEASE LIST ANY ACTIVITIES THAT DECREASE YOUR PAIN/SYMPTOMS? WHAT IS YOUR LEVEL OF PAIN RIGHT NOW? NO PAIN WORST PAIN EVER ****ARE YOU CURRENTLY RECEIVING OR HAVE YOU RECEIVED HOME HEALTH CARE WITHIN PAST 60 DAYS? YES/NO If yes, what dates did you receive services? COMPANY NAME? *****HAVE YOU RECEIVED YSICAL THERAPY WITHIN THE CALENDAR YEAR? YES/NO HOW DID YOU HEAR ABOUT PT SOLUTIONS? Physician Web site/advertisement Friend/Family/Co-worker Insurance company Coach/ Athletic Trainer Other Who may we thank for referring you? Describe your pain. Use all that apply. Sharp Dull Tingling Tight Shooting Throbbing Numb Pulling Burning Ache Heavy Stabbing Describe the behavior of your symptoms. Use all that apply. Constant (Never goes away) Intermittent (relieved with some positions or rest) Occasionally (Daily or less frequent) Infrequently (once a week or month) Previously (No longer present) Variable (Sometimes worse than other times) CIRCLE AREA OF PAIN ON THE DIAGRAM PRIVACY NOTICE I, the undersigned, do hereby acknowledge that I have been made aware of the legal duties and policies and procedures of PT Solutions regarding the protection of my personal health information. I understand and agree that, unless I request otherwise in writing, PT Solutions will communicate with me via phone, fax, and and will state the company name when leaving messages for me via any of these means. Additionally, I have been informed of the company name and I am aware of how I may contact the Privacy Officer should I have questions or comments regarding the privacy practices of PT Solutions. SIGNATURE OF PATIENT, GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE SIGNED
3 MEDICAL HISTORY SCREENING FORM To best serve your needs and understand your medical condition please complete the following. Thank you for your patience. Please circle yes or no and list where appropriate: Patient Family Have you or any immediate family member ever been told you have or are you aware of symptoms related to.. Cancer? Diabetes? High blood pressure? Heart disease/heart attack? Angina/Chest pain? Stroke? Osteoporosis or Osteopenia? Osteoarthritis? Rheumatoid arthritis? Other? _ Do you have a history of: Allergies/Asthma? Are you under stress? Headaches? Are your symptoms getting Worse The same Improve Bronchitis? How are you able to sleep? Fine Moderate Medicate Kidney disease/problems? Do you have a problem with Vision Hearing Speech Rheumatic fever? How do you learn best? Seeing Doing Hearing Ulcers? Do you drink alcohol? Yes _/week No Sexually transmitted disease? Do you or have you smoked? Yes _Packs/Day Yrs No Seizures? Describe your activity level Minimal Moderate High Nervous disorders? Date of last medical examination / / Hernia? List of Medications you Metal implants? currently use: Pacemaker? Dizziness/Balance problems? Are you pregnant? Sensitive to heat/ice? Are you depressed? In the past 3 months, have you had or did you experience: A change in your health? Nausea/vomiting? Fever/chills/sweats? Unexplained weight change? Numbness or tingling? Changes in appetite? Difficulty swallowing? Changes in bowel or bladder dysfunction? Shortness of breath? Dizziness? Upper respiratory infection? Urinary tract infection? Patient Signature: Date of Completion:
4 Welcome to PT Solutions! Please take a minute to review our financial policies, which are designed to clarify your billing and payment questions and assist us in serving you. For your convenience, we will verify your insurance benefits and make our best effort to inform you of any services that your insurance may not cover. We will file for you all insurance claims for services rendered, and make every effort to obtain reimbursement. However, you are ultimately responsible for insuring we are appropriately reimbursed for the charges incurred during the course of your treatment. Any unmet deductible and co-insurance amounts, according to your insurance benefits, will be collected at the time of service. Should your insurance company decline to pay for rendered services or should there be any remaining balance that is your responsibility, our billing office will forward a statement to you. We will gladly accept cash, checks, and credit cards for your payment. If a check for payment is returned from our bank there will be a $30 returned check fee added to your account. This fee will need to be paid at your next visit. This could result in no longer being able to accept a check for payment. At PT Solutions, we are dedicated to providing the best possible service for you. If you have any questions or concerns, please feel free to contact our Office Manager. Please note the following policies pertaining more specifically to your insurance coverage. Private and Commercial Insurance Billing and Payment Policies: Physical Therapy is usually covered under the major medical portion of most commercial insurance policies. Therefore, your insurance carrier may hold you responsible for a major medical deductible and coinsurance portion of the services you receive. We will verify all benefits and inform you of those services your insurance carrier may not cover. Based on the information provided by your insurance company during insurance verification, we will estimate the portion of charges for which you should be responsible, taking into consideration coordination of benefits, should you have coverage under multiple insurance policies. If your insurance company requires prior authorization or precertification for treatment, we ask that you play a proactive part in insurance that all visits are properly pre-approved. In the event that your insurance company considers our services to be out of network, we will make every effort to accommodate their requirements and will work with you to ensure that you receive your necessary care. Your insurance benefits are: Deductible (Unmet portion): $ Copay: $ per visit Coinsurance: % per visit
5 Medicare Billing and Payment Policies: Medicare covers our services under the Part B, major medical portion of your policy. Therefore, if you do not have a supplemental insurance policy, you will be responsible for satisfying your deductible and 20% of all Medicare allowed fees and we ask that you pay any applicable deductible and co-insurance amounts at each visit. We will inform you of any charges which we anticipate Medicare may not cover and ask that you pay for these services when rendered Worker s Compensation Requirements and Payment Policies: It is ultimately your responsibility to adhere to all conditions and policies set forth by your employer s workers compensation carrier to insure they will pay for our services, including but not limited to utilizing specific approved care providers and obtaining prior authorization for treatment. Most workers compensation carriers require prior approval/precertification before services are provided. We ask that you confirm that each visit has been approved prior to your visit. In the event that your employer denies responsibility for your injury or you do not adhere to your employer s guidelines, you will be responsible for the charges that are incurred during the duration of your treatment. Please notify us immediately if it is determined that your employer will not be covering your injury, so we can discuss alternatives, such as billing your private health insurance. Our office is willing to work with you and coordinate with your health insurance company to insure that you receive the maximum benefits, as outlined in your policy. Auto Insurance/ Accident Billing and Payment Policies: If your injury is a result of an auto or other accident for which a third party may be liable, the insurance for the other party likely will not agree to pay us until you have achieved your maximum recovery sign documentation releasing the third party from any further liability. Therefore, we cannot wait for this reimbursement. We will bill your personal auto or liability insurance, if indicated, as your primary payer, and we will then bill your personal health insurance. You will be asked to pay any deductibles and coinsurance portion at the time of service. If you retain an attorney to assist with reimbursement for this injury, please forward your attorney s name and phone number to us as soon as possible. If you have any questions of concerns about our billing and payment policies, please feel free to ask our office staff. We are here to assist. I have read and understand these billing and payment policies and my responsibilities in order to ensure appropriate reimbursement for the services I receive. Signature Date
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):
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
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(
PATIENT REGISTRATION
PATIENT REGISTRATION NAME: HOME ADDRESS: CITY, STATE, & ZIP CODE: HOME PHONE: CELL: WORK: SOCIAL SECURITY NUMBER: SEX: MALE/FEMALE DATE OF BIRTH: AGE: EMERGENCY CONTACT: RELATIONSHIP: EMERGENCY CONTACT
Patient Information. 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:
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
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
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
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
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
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
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
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 ( )
X Guarantor/Parent/Guardian Signature
Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency
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
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
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
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
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
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
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):
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
Valk THE SPORTS REHABILITATION CENTER
Valk Welcome to The Sports Rehabilitation Center. Our services include physical therapy by a licensed physical therapist. We appreciate your selection of our facility to serve your rehabilitation needs.
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
Thank you for choosing ALTITUDE PHYSICAL THERAPY, a Member of the P3 Network - PT-MD Kinect LLC & Partners in Health Healing Center
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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:
Grey Physical Therapy and Sports Medicine Center
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Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
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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
PATIENT INSURANCE AUTHORIZATION WORKSHEET
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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
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
Orthopedic Specialists Of SW FL New Patient Information Form
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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
460 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
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):
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
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
Westoaks Orthopaedic Associates
Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: Email: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician:
Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
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
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?
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,
Made to Move Physical Therapy, Inc. 615 N Nash St., Ste # 306 El Segundo, CA 90245 310.535.0008
Name Last First MI Date Current/Permanent address City State Zip Phone H W Cell Email Address: Marital Status Single Married Other Date of Birth: Age: Gender Male Female Spouses DOB: Employer Occupation
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?
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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 Questionnaire Auto-Collision
Patient Questionnaire Auto-Collision Patient Name: (First) (Middle) (Last) (Suffix) Today's Date: / / Birth Date: / / Age: SSN: Gender: (circle) F M Height: ft in Weight: lbs (circle one) Right handed
PATIENT INFORMATION SPOUSE/PARENT/GUARANTOR INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION LAST NAME: FIRST NAME: MI: DAYTIME PHONE: DATE OF BIRTH: AGE: SEX: EMAIL ADDRESS: MALE MAILING ADDRESS: CITY: STATE: ZIP: FEMALE PHYSICAL ADDRESS (IF DIFFERENT THAN ABOVE): CITY: STATE:
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
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
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
Dear Patient: Photo ID Insurance card(s) Prescription/referral for physical therapy Any Claim documentation (auto/w/c)
7500 Hanover Pkwy Ste. 103 Greenbelt, MD 20770 Phone: 301.446.1644 Fax: 301.446.1647 6510 Kenilworth Ave. Ste. 1100 Riverdale MD 20737 Phone: 240.770.8750 Fax: 240.770.8156 Dear Patient: Attached is your
Street Address (Students-Permanent Address): Apt #: City: State Zip Birthdate Age: Sex: M/F. Home Phone Business Phone Cell Phone Social security #
CARR PHYSICAL THERAPY CENTER Patient's First Name Mi: Last Name PATIENT INFORMATION FORM Street Address (Students-Permanent Address): Apt #: City: State Zip Birthdate Age: Sex: M/F Home Phone Business
Welcome to Central Florida Foot and Ankle Center
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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
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
ADMISSION FORM PERSON WHO SIGNS CONSENT AND IS RESPONSIBLE FOR BILL. Primary Insurance: Phone: Friend/Relative? Who? Physician: Insurance:
ADMISSION FORM An Affiliate of DENVER PHYSICAL THERAPY PATIENT INFORMATION Patient Name: Address: Home Ph#: Work Ph#: Email Address: Employer Name: Employer Address: Date Injured: SS#: Marital Status:
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
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
PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:
PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE
Physical Therapy Services Medical History Form
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317 N. EI Camino Real, Suite 405 Encinitas, CA 92024 (760) 994-2663. Dear Patient:
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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):
WORKERS COMPENSATION INTAKE FORM
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Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our facility.
AVIDAPT 1391 Dublin Rd, Columbus, OH 43215 614-487-9715 avidapt.com Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
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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.
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HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C.
Consent for Care and Treatment I, the undersigned, do hereby agree and give my consent for HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C., to provide Care and Treatment to considered necessary
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
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
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 Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age:
Anthony N. Dardano, D.O., P.A., F.A.C.S. AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY Diplomate of the American Board of Plastic Surgery Diplomate of the American Board of Surgery 951 N.W. 13 th Street,
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)
Advantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
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
Patient Demographics Sheet
Patient Demographics Sheet PLEASE PROVIDE YOUR PHARMACY INFORMATION BELOW: PREFERRED PHARMACY: PHARMACY LOCATION: PHARMACY PHONE NUMBER: FOR OFFICE USE ONLY Dr. Goldblatt Dr. Brown Last Name: First Name:
WELCOME PATIENT CONDITION
NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903 WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer
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
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
(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 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
Orthopedic Specialists Of SW FL New Patient Information Form
Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason
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
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: (
PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT
Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, 72034 501.329.1510 Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex:
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
RIDGEWOOD 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: [ ]
Briefly describe the reason for your visit today (diagnosis, body part, or physical complaint):
Patient Registration Form Today s Date / / Last Name First Middle Date of Birth / / Age: Gender: M F Social Status: Single Married Live with domestic partner Live alone SSN: Contact Information: (please
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.
PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:
PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email
Joint 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
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.
Hand & Orthopedic Physical Therapy Associates, P.C.
Patient Name: Hand & Orthopedic Physical Therapy Associates, P.C. Date of Birth: ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) NOTE: If Medicare doesn t pay for items listed below, you may have to pay.
Mangione Physical Therapy Please read and complete carefully by printing in ink. Provide all information requested.
Whom may we thank for referring you? Mangione Physical Therapy Please read and complete carefully by printing in ink. Provide all information requested. Name: Date of Birth Age: Address: City: State: Zip:
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
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 #:
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)