Houston Healthcare Therapy Agreement



Similar documents
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL Phone: Fax:

New Patient Registration Information

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)

AON Physical Therapy & Wellness

Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D

Dear Patient: Photo ID Insurance card(s) Prescription/referral for physical therapy Any Claim documentation (auto/w/c)

X Guarantor/Parent/Guardian Signature

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

Welcome to Back Country Physical Therapy, Intake Form

Personal Injury Intake Form

920 NE 112 th Avenue, Suite 103, Vancouver, WA Phone: Fax:

Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL Phone: Fax:

Orthopedic Initial Questionnaire. Date: Weight:

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )

THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!

INTEGRATED PHYSICAL THERAPY a whole- istic approach to physical therapy

BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:

Orthopedic Initial Questionnaire

Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.

Welcome to Tri-State Rehab Services

PATIENT REGISTRATION

RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form

PATIENT REGISTRATION

PATIENT INFORMATION FORM

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.

Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Address

How To Get A Physical Therapy At West Point Physical Therapy Center

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.

Advantage Physical Therapy Patient Registration

PRO SPORTS THERAPY, INC. (P.S.T.)

Medical History Questionnaire

INTEGRATED PHYSICAL THERAPY A Holistic Approach to Physical Therapy

ADMISSION FORM PERSON WHO SIGNS CONSENT AND IS RESPONSIBLE FOR BILL. Primary Insurance: Phone: Friend/Relative? Who? Physician: Insurance:

RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION

REHAB XCEL, LLC. NEW PATIENT INFORMATION

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470

Patient Information: In Case of Emergency: Physician: Insurance:

North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip:

City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:

Guardian/Patient Name. Family Dental Care NC Country Club Rd---Jacksonville, NC Telephone: (910) SIGNATURE ON FILE

VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC PH FAX Scott W. Baker, MD. Patient Instructions

HI *Home Phone: Alternate Phone: Driver License No.: Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)

Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:

MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION

Function First Physical Therapy, P.C. Patient Intake Form

Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )

PERSONAL INFORMATION

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.

Grey Physical Therapy and Sports Medicine Center

11120 New Hampshire Ave., Suite 411 Silver Spring MD Office (301) Fax (301)

Orthopaedic Institute of Ohio Demographic Information Date:

REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)

1455 West Fair, Marquette, MI Phone // Fax // info@mqtrehab.com

EASTERN CONNECTICUT REHABILITATION CENTERS PHYSICAL THERAPY INFORMATION PACKET

Mangione Physical Therapy Please read and complete carefully by printing in ink. Provide all information requested.

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )

CORONADO EYE ASSOCIATES GLENN B. COOK, M.D., PhD 801 ORANGE AVENUE, STE CORONADO, CA FAX

Welcome! We look forward to serving YOU. If we can do anything to make your time with us more enjoyable, please let us know.

Midha Medical Clinic REGISTRATION FORM

PATIENT REGISTRATION FORM

IMS Allergy & Immunology New Patient Registration Sheet. Personal Information

William O. Reed, Jr. M.D., P.A W. 74 th Street, Suite 354 Overland Park, KS Fax:

LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA (318) FAX: (318)

RETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number:

Hand & Orthopedic Physical Therapy Associates, P.C.

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas Today s Date: How did you hear of our practice?

How To Get A Medical Checkup

Physician address. Physician phone

Atlantis Physical Therapy Associates

Dear Patients and Prospective Patients:

PATIENT INFORMATION INSURANCE INFORMATION

Physical Therapy Services Medical History Form

Next Level Physical Therapy PC Patient Information

California Pain Consultants - PATIENT REGISTRATION FORM

Insurance card Picture ID MRI/X-ray reports Therapy referral from referring physician Insurance referral if required from your insurance carrier

Transcription:

Houston Healthcare Therapy Agreement We will do our best to: Begin all sessions on time Explain your treatment program and progress to you Accommodate your schedule Be consistent with your therapist and assistant Reschedule if you must miss an appointment We ask you to: Arrive on time for all sessions Participate in setting your therapy goals Call at least 24 hours ahead of time if you need to cancel an appointment (pain is not a reason to cancel a session) Follow recommended home activities and exercise programs Dress appropriately for your therapy (wind suits, walking shorts and sweat pants are recommended) Our department guidelines are as follows: Three cancellations without notice will be automatic grounds for discontinuation of services Every effort will be made to keep you with the same therapist/assistant; however, there may be circumstances when another therapist will need to provide your treatment Every effort will be made to give you your preferred appointment time as the schedule allows All co-pays are due at time of service The goal of our staff is to provide excellent service and care for each patient on an individual basis. We will assist you in every way to achieve a positive outcome. If you have any questions please feel free to speak with your therapist. Name: DOB: Client signature: Date: Staff signature: Date: Pavilion Rehab Houston Lake Rehab 233 North Houston Road, Suite B 2510 Highway 127 Warner Robins, Georgia 31093 Kathleen, Georgia 31047 478.923.2937 478.988.1882 1

Registration Form NAME DOB AGE SEX MARITAL STATUS TELEPHONE - - PATIENTS SS# - - CELL PHONE - - ADDRESS CITY STATE ZIP CODE COUNTY REFERRING PHYSICIAN PRIMARY PHYSICIAN EMPLOYER EMPLOYER PHONE EMPLOYER ADDRESS CITY STATE IF RETIRED, GIVE DATE SPOUSE RETIRE DATE GUARANTOR INFORMATION IF PATIENT IS A MINOR NAME OF PARENT OR GUARDIAN RELATIONSHIP ADDRESS PHONE - - EMERGENCY CONTACT INFORMATION NAME PHONE - - ADDRESS CELL PHONE - - RELATIONSHIP TO PATIENT NEAREST RELATIVE PHONE - - ADDRESS RELATIONSHIP 2

INSURANCE INFORMATION PRIMARY INSURANCE POLICY # INSURANCE PHONE - - ADDRESS SUBSCRIBER NAME GROUP # (If different from patient) ADDRESS CITY STATE ZIP DATE OF BIRTH SS# RACE SEX MARITAL STATUS IF RETIRED, GIVE DATE SPOUSE RETIRE DATE SECONDARY INSURANCE POLICY# INSURANCE PHONE - - ADDRESS SUBSCRIBER NAME GROUP # (If different from patient) ADDRESS CITY STATE ZIP DATE OF BIRTH SS# RACE SEX MARITAL STATUS ADDITIONAL INSURANCE INFORMATION *WORKER S COMPENSATION EMPLOYER CLAIM # MAILING ADDRESS CONTACT NAME PHONE - - *AUTOMOBILE LIABILITY DATE OF INJURY NAME OF INSURED PHONE - - INSURED S ADDRESS RELATIONSHIP INSURANCE COMPANY PHONE - - CLAIM # CONTACT 3

GENERAL MEDICAL HISTORY NAME INJURY DATE PROBLEM AREA ARE YOU CURRENTLY WORKING? Y N TYPE OF WORK REGULAR DUTY LIGHT DUTY MEDICAL LEAVE HAND DOMINANCE RIGHT LEFT PLEASE CHECK IF YOU HAVE BEEN TREATED FOR: ( ) HEART ATTACK ( ) KIDNEY DISEASE ( ) PACEMAKER ( ) ANY INFECTIOUS DISEASE: (TB, AIDS, ( ) HERNIAS HEPATITIS) ( ) HIGH BLOOD PRESSURE ( ) DIABETES ( ) LUNG DISEASE/PROBLEMS ( ) METAL IMPLANT/JOINT REPLACEMENT ( ) HEAD TRAUMA/CONCUSSION ( ) PSYCHIATRIC/EMOTIONAL PROBLEMS ( ) STROKE ( ) ARE YOU PREGNANT? ( ) DIZZINESS/BALANCE PROBLEMS ( ) ALLERGIES: (LATEX, MEDICATION, FOOD) ( ) TOBACCO USAGE ( ) BACK/NECK INJURIES ( ) CANCER ( ) ARTHRITIS ( ) GASTROINTESTINAL PROBLEMS ( ) FRACTURES ( ) JOINT DISLOCATION LIST CURRENT MEDICATIONS HAVE YOU RECENTLY HAD AN X-RAY, MRI, AND/OR CT SCAN FOR YOUR CONDITION? FINDINGS DATE PLEASE LIST ANY MAJOR SURGERY/HOSPITALIZATIONS WITHIN THE PAST FIVE YEARS: REASON DATE REASON DATE HAVE YOU EVER BEEN EVALUATED AND/OR TREATED BY ANY OTHER PHYSICAL THERAPIST, OCCUPATIONAL THERAPIST, CHIROPRACTOR, OR HEALTH CARE PRACTITIONER FOR THIS CONDITION?

Rehab Outcomes Intake Patient Name: DOB Date Pain On a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain, place an X on the scale below to rate your current level of pain. No Mild Moderate Severe Extremely Pain Pain Pain Pain Severe Pain 0 2 5 8 10 Motion On a scale of 0 to 10, with 0 showing no limitations in your ability to move and 10 being unable to, place and X on the scale below for your current level of motion (bending over, reaching overhead, twisting your trunk, etc.) No Minimal Moderate Severe Unable Limitation Limitation Limitation Limitation to Perform 0 2 5 8 10 Function On a scale of 0 to 10, with 0 being able to perform your entire normal daily activities, and 10 being that you are unable to perform any of your normal daily activities, place an X on the scale below for your current ability to perform your normal daily activities. No Minimal Moderate Severe Unable Limitation Limitation Limitation Limitation to Perform 0 2 5 8 10 Insurance: Zip Code: MD: 5

PAVILION REHAB HOUSTON LAKE REHAB 233 North Houston Road, Suite B 2510 Highway 127 Warner Robins, Georgia 31093 Kathleen, Georgia 31047 478.923.2937 478.988.1882 As a courtesy, we try to verify your therapy benefits prior to your first visit. However, it is your responsibility to inform us if referrals or limitations are required by your policy. If you wish your claims to be filed to another insurance company other than your group health insurance, you must provide the necessary information. Signature: Date: 6

2026 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information