Patient Express Registration
|
|
- Deborah Stevens
- 6 years ago
- Views:
Transcription
1 Patient Express Registration South Aiken Physical Therapy Todays Date: 1. Patient Info IMPORTANT: Please Fill-Out This Form Completely & Legibly (please do not leave any items blank) Your Full Name (check one Mr Mrs. Ms.) Date of Birth Gender: M F Address Home Address City State Zip Code Your Hm Phone ( ) Cellular ( ) Emergency Contact Person My condition is related to: Work Auto Accident (state ) Other: How did you hear about us? Why did you choose this clinic? Family MD If you were injured on the job, complete below; Social Security # Occupation Employer Name Adjuster Name Adjuster Phone 3. Important Info We are very committed to you and your goals. We will reserve appointment times for you that allow you the appropriate amount of therapist time for your needs. If you cannot keep your appointment, please call with 24 hours notice if possible so that someone else might benefit from that time. Failure to provide 24 hours notice will result in a fee to you. Nothing will be charged unless you cancel with less than a 24-hour advance notice ($10 fee) or fail to show ($25 fee). Phone 2. Payment Info (check only one box) I am not using health insurance. I am paying by CASH, CHECK, CREDIT and would like a... q 30% discount by paying at the time of service. q Payment plan. (Fees may apply). OR I have INSURANCE and would like to... q Have you deal directly with them. I will assign my benefits to you by completing the Assignment of Benefits Form. I understand that I am responsible for any deductible, copayment or co-insurance associated with my insurance plan. I also understand that my insurance plan may not cover all services received in Physical Therapy and that I am responsible for any non-covered expenses. My coinsurance/copay is $ My deductible is $ I was injured on the job and my employer will be paying for my Physical Therapy. (Please fully complete section 1.) 4. Appointment Reminders Would you like to receive appointment reminders for your future visits? Yes No If yes, choose ONE method to receive them? Text message Voice call (phone number) (please enter preferred address)
2 Pre- Exam Questionnaire Patient Name: Date of Birth: Are you currently receiving any Home Health Agency Care? Yes No What is the main problem we are seeing you for today? Which side of your body is affected? Left Right Both Sides Not Applicable When did this problem start? Did you have surgery for this problem? No Yes When What procedure? BEFORE THE ONSET of this problem check any tasks you were unable to do, or had difficulty performing: Grooming Looking after your health Bathing Toileting Sleeping Driving Ability to Handle Phone Ability to Handle Finances Cooking Laundry Volunteer Caregiving Remaining Standing Squatting Kneeling Sitting Standing Move from bed to chair Turning in Bed Rising from a chair Need for Assistive Device Walking forward, back or sideways Walking around obstacles Climbing Running/Jogging/Skipping/Jumping Swimming Walk in home Stairs Walk in Community Walk in Large Building Walking on uneven terrain Pulling Objects Pushing Objects Reaching Turning or Twisting Hands or Arms Throwing Catching Picking up small items Gripping objects Manipulating small items Releasing small objects Kicking Pusing objects with your legs Work Wellness/Recreation 943 Pine Log Road, Aiken SC phone (803) fax (803) help@southaikenpt.com form rev 3/2016 Page1
3 Pre- Exam Questionnaire SINCE THE ONSET of this problem, check which tasks are difficult or are you unable to do? Grooming Looking after your health Bathing Toileting Sleeping Driving Ability to Handle Phone Ability to Handle Finances Cooking Laundry Volunteer Caregiving Remaining Standing Remaining Sitting Squatting Kneeling Standing Sitting Move from bed to chair Turning in Bed Rising from a chair Need for Assistive Device Walking forward, back or sideways Walking around obstacles Climbing Running/Jogging/Skipping/Jumping Swimming Walk in home Stairs Walk in Large Building Keeping balance if bumped in public Walking on uneven terrain Pulling Objects Pushing Objects Reaching Turning or Twisting Hands or Arms Throwing Catching Picking up small items Gripping objects Manipulating small items Releasing small objects Kicking Pushing objects with your legs Work Wellness/Recreation If we are seeing you for a pain problem today, please tell us more about it: Where is your pain? How would you rate your pain on a scale of 0-10 (0 is no pain, 5 is moderate pain, 10 is excruciating pain): At Worst, Currently, At Best Describe you pain further by checking all applicable descriptions: Burning Sharp Dull/Achy Throbbing Shooting Numb/Tingle Constant Intermittent Worse in AM Worse in PM Worse at Night Other: What makes your pain worse? What makes your pain better? 943 Pine Log Road, Aiken SC phone (803) fax (803) help@southaikenpt.com form rev 3/2016 Page2
4 Pre- Exam Questionnaire How would you describe your general health? Good Fair Poor Other: (For persons aged 65 or older only) How many falls have you had in the past 12 months (please circle): or more Did any falls result in an injury (please circle): Yes No Please tell us more about your Medical History. Please check any that apply: I have no Known past medical history to affect treatment Alzheimer s Cardiovascular Disease Pacemaker Hypertension Stroke Diabetes Type 1 Diabetes Type 2 Fibromyalgia History of Cancer Immunosuppression Lupus Muscular Dystrophy Obesity Osteoarthritis Parkinson s Rheumatoid Arthritis Traumatic Brain Injury Other: If you have had any diagnostic tests for this problem please note here: (i.e. Xray, MRI, CT scans ) Do you have any unexplained weight loss? Yes No Medications: I am currently not taking any medications (proceed to next page) I have provided a separate medication list to scan into my medical record (proceed to the next question) Attention Medicare Beneficiaries: regulations require us to collect details about every medication you take: name, the dosage, the frequency and the route that the medication is taken (for example oral, injection, topical, sublingual). If you have not provided us with this list then please provide this information as detailed as you possibly can below: Prescription Dosage Route(oral/topical/sublingual/IV) Over The Counter Herbals Vitamin/Mineral/Supplements 943 Pine Log Road, Aiken SC phone (803) fax (803) help@southaikenpt.com form rev 3/2016 Page3
5 Pre- Exam Questionnaire List one or two things you are having difficulty doing now that you would like to be able to do better after Physical Therapy; i. ii. Signature (parent/guardian if under 18) Please Print Name Date OFFICE USE ONLY: Height (inches) Weight (pounds) Source: SAPT Outside medical record Blood Pressure Patient refuses height and weight measurement (N = Age 65 & older BMI 23 and < 30 kg/m2 ; Age BMI 18.5 and < 25 kg/m2) 943 Pine Log Road, Aiken SC phone (803) fax (803) help@southaikenpt.com form rev 3/2016 Page4
6 Patient Name (please print) Date / / Consent to Treat The undersigned grants authority to South Aiken Physical Therapy, LLC (SAPT) and its staff to perform procedures and treatments deemed necessary for this patient and generally are used in the care of patients in this and similar Physical Therapy facilities. Additionally, the undersigned grants permission for the SAPT staff to provide emergency treatment if it is needed, or to transfer this patient to a local hospital for emergency treatment deemed necessary by the hospital medical staff. Signature of Patient/Parent/Guardian/Legal Representative Relationship to Patient (if applicable) Acknowledgement of Notice of Privacy Practices The undersigned acknowledges that he/she has been provided the option to receive a copy of the South Aiken Physical Therapy Notice of Privacy Practices. I understand that SAPT has the right to change it Notice of Privacy Practices and that I may contact SAPT at any time to obtain a current copy of the Notice of Privacy Practices Signature of Patient/Parent/Guardian/Legal Representative Relationship to Patient (if applicable) FRONT OFFICE USE ONLY PLEASE DO NOT WRITE BELOW THIS LINE I have attempted to obtain the patient s signature on this form, but was not able to for the following reason(s): Date: / / Initials:
7 Assignment of Benefits to South Aiken Physical Therapy, LLC Patient Name: Patient DOB: Policy Holder Name: Policy Holder DOB: I hereby instruct and direct by check made out and mailed to: insurance company to pay South Aiken Physical Therapy 943 Pine Log Road Aiken, SC This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above- mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. (Check each box and sign below) q A photocopy of this Assignment shall be considered as effective and valid as the original. q I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits. q I authorize the use of this signature on all insurance submissions. q I authorize South Aiken Physical Therapy, LLC to initiate a complaint to the Insurance Commissioner for any reason on my behalf. q I understand that I am financially responsible for all charges whether or not paid by insurance. Date / / Signature of Policyholder Signature of Claimant, if other than Policyholder If applicable, please read and sign below: I am 18 years old or younger and I hereby agree that South Aiken Physical Therapy may release any necessary payment information to my parent(s)/guardian(s). Signature of Patient Date / /
8 South Aiken Physical Therapy Patient Policies Creating the Best Rehabilitation Environment in Aiken: Our patients say that our care system is second-to-none. Here s what just a couple of patients have to say; I had almost immediate improvement and relief of symptoms. Book him! Alyssa D. I got better and the pain has not reoccurred. If you are considering this therapist you are making a good decision...i already have recommended him to family and friends Ron S. We attribute part of our success to the policies and beliefs we uphold; Important Patient Policies (Initial all boxes please) Do not be late. If you are more than 10 minutes late to your appointment you will be asked to reschedule. We avoid booking overlap as this compromises both yours and another patients care. Give 24-hr advance notice. A $10 fee* will be applied to your account for any reschedules or cancellations made with a less than 24 hour advance notice. Advance notice helps us schedule in place of you, other patients who need it. No-Shows are bad. We understand things happen. If you are unable to keep your appointment please call and let us know. Simply not showing up will result in a $25 fee* and the loss of all scheduled future appointments. New appointments will be allowed on a first-come, first-served basis. Payment is due at the time of service. How much you pay is a contract between you and the insurance company. We are not a party to that contract. We can deal directly with your insurance company for payment and to handle disputes if you sign the Assignment of Benefits form. You are responsible for payment of your account. Our fees are generally considered to fall within the range for this geographic area. Some insurance companies reimburse on an arbitrary schedule of fees and arbitrarily select which services to cover. Non-covered services are the responsibility of the patient. For insurance companies that we do not have a contract with, the patient is responsible for the difference between the amount billed and the amount paid by the insurance company. No unlawful waiver of patient responsibility payments. We are required to collect your portion of the invoice. No waiver, discounts, or special treatment can be awarded outside of documented financial hardship (federal guidelines used ask at the front desk for an application if you think you qualify). We accept cash, check, MasterCard and Visa. Accounts 30 days past due will be subject to 9.9% interest per month. Patient Responsibility Payment Extensions are available. If you are unable to pay your co-payment, co-insurance or deductible at the time of service you can make arrangements with the Receptionist to fill out a Request for an Extension Form. There is a $7.00 fee for this service to you. Individualized payment plans are available for a one-time $29 fee. A$25 charge applies for returned checks. I have carefully read and agree to all the above policies. In the event such policies are broken, I agree to the consequences set forth. Signed date / / * We take great pride in being a low patient volume practice and offering personalized service. These fees in no way cover our cost in keeping this spot for you. They are to encourage you to keep your appointments so that you may best achieve your goals or to call to allow us the time to offer your space to others who may need it. 943 Pine Log Road Aiken SC ph fax
Last Name First Name M.I. Street Address City State Zip. Home Phone ( ) Cell Phone ( ) Work Phone ( ) Emergency Contact: Name/Relation Phone Number(
TODAY S DATE Last Name First Name M.I. Street Address City State Zip Home Phone ( ) Cell Phone ( ) Work Phone ( ) Emergency Contact: Name/Relation Phone Number( ) Social Security Number - - Date of Birth
More informationNew Leaf Physical and Massage Therapy LLC 1 of 5 HEALTH INTAKE FORM. Name Date of Birth
New Leaf Physical and Massage Therapy LLC 1 of 5 HEALTH INTAKE FORM Please fill out form entirely and bring it with you to your first office visit. Name Date of Birth A. Reason for Visit Reasons for your
More informationNewspaper Past Patient / Friend Medical Doctor Website Yellow Pages Other:
Patient Information New Patient Returning Patient Email: Patient Name: Address: STREET # OR P.O. BOX CITY STATE ZIP CODE Date of Birth: Age: MALE FEMALE SS#: Home Phone: Work or Cell Phone: Patient Status:
More informationPlease feel free to ask questions about this document. I have read the above guidelines and agree to the terms set forth by A Joint Effort PT.
Please arrive to your initial appointment at least 15 minutes early. For all following appointments, please arrive 5 minutes prior to you scheduled appointment time. To avoid waiting unnecessarily remember
More informationPATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber
PATIENT INFORMATION : Please present insurance cards to receptionist First Name: Last Name: Date of Birth: - - Sex: Male Female Address: City: Cell Phone #: ( ) - M.I.: APT: State: Zip Code: Home #: (
More informationPatient Registration. D. INSURANCE (if applicable)
A. PATIENT Please Print Legibly Account #: Address: City: State: Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone Patient Registration DOB: SSN #: Gender: Male Female E-MAIL: Check here
More informationCity: State: Zip: Home Cell Work Alternate Phone: Address: Home Cell Work Sex: Male Female Marital Status: Single Married Other:
Denton Sanger Aubrey Patient Information Patient Registration Information Name: (First) (MI) (Last) Social Security #: Date of Birth: Address: Phone: City: State: Zip: Home Cell Work Alternate Phone: Email
More informationPatient Registration. D. INSURANCE (if applicable)
Patient Registration A. PATIENT Account #: Address: City: State Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone DOB: SSN #: Gender: Male Female E-MAIL: Check here to receive Electronic
More information920 NE 112 th Avenue, Suite 103, Vancouver, WA Phone: Fax:
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 informationPersonal Insurance Intake Form
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
More informationWorker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
More information4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /
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: Male Female 6) Date of Birth (DOB):
More informationAgape Physical Therapy and Sports Rehabilitation. Patient Name: Birthdate Social Sec.
INSURANCE INFORMATION As a courtesy to our patients, we will verify and file your insurance claim; HOWEVER, we cannot guarantee payment by your insurance company. We strongly suggest that you read your
More informationName: Employer: Phone: Phone: Social Security: Occupation: Previous Therapy: Primary Doctor: Phone number: Fax Number: Referring Doctor:
PATIENT INTAKE FORM Patient Information Hands On Physical Therapy Please fill this form out completely. Thank You! Name: Employer: Address: City/State/Zip: Address: City/State/Zip: Phone: Phone: Date of
More informationPATIENT INFORMATION HISTORY OF CURRENT PROBLEM CURRENT MEDICATION
PATIENT INFORMATION NAME: LAST: FIRST MI E-MAIL ADDRESS CITY: STATE ZIP HOME PHONE: WORK CELL SEX M [ ] F [ ] AGE: DATE OF BIRTH: [ ] SINGLE [ ] MARRIED [ ]WIDOWED [ ]DIVORCED PLACE OF EMPLOYMENT JOB TITLE
More informationDate: First Name: MI: Date of Birth: / / Last Name: Social Security Number: / / Preferred Name: Sex: Gender: Marital Status: Single Married Other
PATIENT INFORMATION Date: First Name: MI: Date of Birth: / / Last Name: Social Security Number: / / Preferred Name: Sex: Gender: Home Address: City: State: Zip Code: Marital Status: Single Married Other
More informationPatient Information Page 1 of 2 *We cannot process your insurance claims without the required fields filled out.
Patient Information Page 1 of 2 *We cannot process your insurance claims without the required fields filled out. Patient s Name*: Today s Date: Street address*: SSN*: City and State*: Zip Code*: Gender:
More informationAdvanced Therapy Solutions
Advanced Therapy Solutions Patient First Name Address City State Zip Social Security # Date of Birth / / Sex: M or F Drivers License # Marital Status: Single, Married, Divorced Email Address: @ Home Phone
More informationONEACCORD PHYSICAL THERAPY CASA GRANDE, GILBERT & PHOENIX, AZ REGISTRATION FORM PATIENT INFORMATION. q Mr. q Mrs.
ONEACCORD PHYSICAL THERAPY CASA GRANDE, GILBERT & PHOENIX, AZ REGISTRATION FORM Today s date: Primary Doctor: PATIENT INFORMATION Patient s last name: First: Middle: Is this your legal name? q Mr. q Mrs.
More informationPATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:
PATIENT INFORMATION PERSONAL INFORMATION Today s Date: Check the type of care desired: Temporary Relief Lasting Correction Name: Social Security Number: - - Date of Birth: - - Age: Height: Weight: Check
More information4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /
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: Male Female 6) Date of Birth (DOB):
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 informationPATIENT INFORMATION Patient Demographics and Insurance
PATIENT INFORMATION Patient Demographics and Insurance PERSONAL INFORMATION Last First MI Suffix Social Security # Date of Birth Sex Marital Status Primary Phone Alternate Phone Email Address Address City
More informationCore Physical Therapy, PC & Integrated Center for Optimum Health, LLC
Core Physical Therapy, PC & Integrated Center for Optimum Health, LLC New Patient Information (Please Print Clearly) Date: / / Patient Name: Sex: Male Female Last First M.I. Address: Street City State
More informationCurrent symptoms, conditions, and complaints:
Medical History Form Name: : Have you RECENTLY noted any of the following (check all that apply)? Changes in bowel or bladder function Weight loss/gain Fever/chills/sweats Shortness of breath Severe constant
More informationClient Information Juneau Physical Therapy
Client Information Patient Name Date of Birth Social Security # Sex F M Mailing Address City State Zip Home Phone Cell Phone Work Phone Email Address (optional) Patient Employed by Emergency Contact Relationship
More informationTotal Wellness Medical Care. Patient Medical History
Today s date: PCP: Patient's last name: Mr. Mrs. Marital Status: (circle one) Patient s first name: Ms. Miss Single/Married/Divorced/Separated/ Widowed Is this your legal name? Yes or No If not, what is
More informationUltimate Therapy Merchants Lane, Suite 202 Leonardtown, MD ( ) ( ) Home Phone Cellular Address ( ) Occupation Employer Name Phone #
Ultimate Therapy 40900 Merchants Lane, Suite 202 Leonardtown, MD 20650 Patient Information Last Name First Name Age Sex M F Street Address City State Zip ( ) ( ) Home Phone Cellular Email Address ( ) Occupation
More informationMedical Information Sheet
Medical Information Sheet Name: Date: Age: Sex: M F Height: Weight: Dominant hand: R L Occupation: Presently working: Y N Reason for being seen today: Date of Onset: Involved side: R L Both Describe any
More informationNew Patient Referral and Insurance Verification Form
New Patient Referral and Insurance Verification Form Today s Date: Prior Patient: Y N How did you hear about our practice? Physician: Dr., Internet:, Family/Friend:, Advertising:, Insurance:, Other:. Patient
More informationFirst Name: Last Name: Initial:
Patient Information Sheet Please complete the entire form First Name: Last Name: Initial: Address: City: State: Florida Zip Code: Home: ( ) Work: ( ) Cell: ( ) 420 South Dixie Hwy, Suite 4D Email: Gender:
More informationPatient Registration Form
Patient Registration Form Patient Information Account # : Address: Primary Phone: Please indicate the best number for your appointment reminder calls: Home Cell Text Alternate Phone: Email: May we contact
More informationBack in Motion Physical Therapy P.L.C. Patient Registration and Authorization Form Please Print
Back in Motion Physical Therapy P.L.C. Patient Registration and Authorization Form Please Print Today s Date: Diagnosis: Date of Birth: Patient Name: First Last Social Security #: Male Female Married Single
More informationTHE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Employer s Name School
THE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Sex: M F Employer s Name School Contact Information: Mailing Address City State Zip
More informationPatient s Printed Name:
OSI PHYSICAL THERAPY AUTHORIZATION TO TREAT: I voluntarily consent to therapy care encompassing evaluation and treatment procedures. I acknowledge that no guarantees have been made to me about the results
More informationPATIENT INFORMATION HISTORY OF CURRENT PROBLEM CURRENT MEDICATION
PATIENT INFORMATION NAME: LAST: FIRST MI E-MAIL ADDRESS CITY: STATE ZIP HOME PHONE: WORK CELL SEX M [ ] F [ ] AGE: DATE OF BIRTH: [ ] SINGLE [ ] MARRIED [ ]WIDOWED [ ]DIVORCED PLACE OF EMPLOYMENT JOB TITLE
More informationRavi Yalamanchili M.D, P.A. Patient Registration / Information Sheet Last Name: M.I. Sex: Female Male First Name: Marital Status:
We do not Accept Checks Ravi Yalamanchili M.D, P.A. 141 Thomas Johnson Drive, Suite 200 Frederick, MD 21702 Phone 301-846-0100 Fax 301-846-0244 Please Print Patient Registration / Information Sheet Last
More informationACIC PHYSICAL THERAPY
ACIC PHYSICAL THERAPY PATIENT INFORMATION NAME (first, last): DATE: HOME PHONE: CITY: STATE: ZIP: SSN: DRIVER S LICENSE #: EMAIL: SEX: M F DATE OF BIRTH: AGE: DATE OF INJURY : CAUSE OF INJURY: REFERRING
More informationBenchMark Rehab Partners Welcome to
BenchMark Rehab Partners Welcome to At BenchMark Rehab Partners we believe communication is essential to achieving the best possible patient outcomes. Understanding your needs and expectations is essential
More informationPATIENT INFORMATION. Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:
PATIENT INTAKE FORM (Please Print or Type. Once complete, either fax to 949-553-3561, email to Stacie@thephysiofix.com or bring with you during your first session!) Today s date: PATIENT INFORMATION Patient
More informationPRIME CARE PHYSICAL THERAPY, P.C. NEW PATIENT INFORMATION
PRIME CARE PHYSICAL THERAPY, P.C. NEW PATIENT INFORMATION Patient Name: Last First MI ( ) Male ( ) Female Address: Street City State Zip Code Home Phone: ( ) Cell Phone: ( ) Email Add: Do you prefer to
More informationFirst Name Last Name MI. DOB / / Cell Number Alt. Number. Address City State ZIP Code. Social Security Number Address
DEMOGRAPHICS EMPLOYMENT INFORMATION INSURANCE INFORMATION EMERGENCY CONTACT INFO CLIENT DEMOGRAPHIC First Name Last Name MI DOB / / Cell Number Alt. Number Address City State ZIP Code Social Security Number
More informationMarital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address
More informationKRAIG R. PEPPER, D.O. P.A.
Thank you for choosing Dr. Kraig Pepper, D.O. P.A. for your care. The following is required to provide you with the quality medical care. The doctor and staff will review this information and place it
More informationBack in Motion Physical Therapy P.L.C. Patient Registration and Authorization Form Please Print
Back in Motion Physical Therapy P.L.C. Patient Registration and Authorization Form Please Print Today s Date: Diagnosis: Date of Birth: Patient Name: First Last Social Security #: Male Female Married Single
More informationOrange N. Harbor Blvd., Suite B Fullerton, CA Phone: Fax: New Patient Form. Address: City: State: Zip:
, CA 92866 New Patient Form New Patient: HMO PPO Medicare Work Comp Lien Other Name: Date: Home Phone: Cell: Work: Email: Social Security: DOB: Gender: Drivers License #: Referring Physician: Phone: Primary
More informationHEALTH QUESTIONNAIRE. Today s Date Date of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No
Name HEALTH QUESTIONNAIRE Today s of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No If yes, type and amount: Alcohol Use: How many drinks do you have per week? Hand Dominance: Left
More informationJoint Effort Rehab, LLC
Patient Information DEMOGRAPHICS Joint Effort Rehab, LLC New Patient Forms First Name: MI: Last Name: Sex: M F Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: *Email SSN#: of Birth: *By
More informationAdvanced PT, LLC 200 W Douglas Ave, Ste 1040 Wichita, KS (866)
200 W Douglas Ave, Ste 1040 Wichita, KS 67202 (866) 412-5554 Welcome to Advanced PT, LLC. We are honored that you have chosen us as your therapy provider. Our goal is to provide the highest quality of
More informationPatient Registration & Health History
Patient Registration & Health History Today s Date: / / How did you hear about us? Legal Name: How do you prefer to be addressed? Address: City: State: Zip: Date of Birth / / Age: Gender: M / F Marital
More informationPraxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL Phone: Fax:
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 informationName: Date: DOB: / / Age: Nickname (if applicable): Height: Weight: Hand Dominance: R / L
Medical History Name: Date: DOB: / / Age: Nickname (if applicable): Height: Weight: Hand Dominance: R / L Allergies (medications and/or metals): NKDA / PCN / Sulfa / Latex Occupation (if retired, what
More informationKORT New Patient Information
KORT New Patient Information Patient Address: City/State/Zip: E-Mail Address: Date of Birth: / / Age: Sex: Social Security Number: - - Marital Status: Home Phone: Cell phone: Employer/School: Employer
More informationRegistration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
More informationPARAGON Physical Therapy, PC
WELCOME TO PARAGON Physical Therapy. Who can we thank for referring you? We appreciate you choosing PARAGON Physical Therapy, PC to be your provider of physical therapy services. If you would not mind,
More informationAre you currently pregnant? ( ) Yes, due date: ( ) No ( ) Unsure
Patient s Full Name: of Birth: Age: Address: City: State: Zip: Patient Social Security #: Gender: Height: Weight: Cell Phone: Other Phone: E-Mail: Preferred appointment reminder: ( )Text: Cell Phone Provider:
More informationPARAGON Physical Therapy, PC
WELCOME TO PARAGON Physical Therapy. Who can we thank for referring you? We appreciate you choosing PARAGON Physical Therapy, PC to be your provider of physical therapy services. If you would not mind,
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 informationFirst Name MI Last Name. Address. City State ZIP. Phone (H) (W) (Cell) (Please circle the preferred contact number) Address
Date of Birth Social Security Number - - First Name MI Last Name Address City State ZIP Phone (H) (W) (Cell) (Please circle the preferred contact number) Email Address Occupation Full Time/Part Time Employer
More informationPATIENT CASE HISTORY
Family Chiropractic Center of Santa Fe 2019 Galisteo St. Suite M6 Santa Fe, NM 87505 505-984-0006 www.spchiro.net PATIENT CASE HISTORY Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell
More informationWelcome to Southwest Diagnostic Center!
Patient Information Form PATIENT INFORMATION Welcome to Southwest Diagnostic Center! Name: Last Name First Name MI Address: City: SS # Email: State: Zip: Sex: M F Age: Birth date: Marital Status: Patient
More information(Formerly AFCN Physical Medicine) A member of the Arkansas Family Care Network, P.A.
Page 1 of 8 (Formerly AFCN Physical Medicine) A member of the Arkansas Family Care Network, P.A. If you have a problem with vision, hearing, speech or communication, please let our front desk personnel
More informationKORT New Patient Information
managed by: KORT New Patient Information Patient Address: City/State/Zip: E-Mail Address: Date of Birth: / / Age: Sex: Social Security Number: - - Marital Status: Home Phone: Cell phone: Employer/School:
More informationPatient Case History
Patient Case History Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Email Address: Preferred Contact: Home Phone Cell Work E-mail Employer & Occupation: Date of Birth:
More informationPatient/Guardian Signature: I hereby agree that the information above is true and accurate. Patient Medical History Form PATIENT MEDICAL HISTORY FORM
PATIENT MEDICAL HISTORY FORM Patient Medical History Form DATE: Last Name: First Name: Chart#: Birth Date: Sex: Male / Female Height: Weight: PATIENT HISTORY AND SAFETY QUESTIONS Physician Name: Do you
More informationCorona-Temecula Orthopaedic Associates P H Y S I C A L T H E R A P Y A N D W E L L N E S S C E N T E R
PATIENT QUESTIONNAIRE Please fill out this form COMPLETELY using your LEGAL name. Do not leave any blanks. FAMILY PHYSICIAN (First Name, Last Name) PATIENT INFORMATION DATE TO SEE DOCTOR (Name) / / PATIENT
More informationPS CHIROPRACTIC PATIENT CASE HISTORY
PS CHIROPRACTIC PATIENT CASE HISTORY Personal Information Last Name First Name Middle Initial Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: age Social Security
More informationPlease list all current medications and supplements that you are taking:
PATIENT HEALTH AND MEDICAL HISTORY Today s Date: Chief Complaint for Today s Visit: Was this injury gradual or sudden onset? Date of sudden onset: Please explain: Do you have a history of present symptoms?
More informationNEW PATIENT CHECKLIST
80 Park Street, Attleboro, Ma 02703 508-223-2300 NEW PATIENT CHECKLIST If you need to see a physical therapist, you want to get the most out of each and every visit. Before you can show up for a visit,
More informationAVIDAPT avidapt.com
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 informationPATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:
PATIENT INFORMATION PERSONAL INFORMATION Today s Date: Check the type of care desired: Temporary Relief Lasting Correction Name: Social Security Number: - - Date of Birth: - - Age: Height: Weight: Check
More informationNew Patient Registration
New Patient Registration Patient Information: Name (Last, First): Date: Address: Street City State Zip Code Phone (Home): (Work): (Cell): Social Security Number: - - Birth Date: / / Sex: ( M / F ) Email:
More informationWELCOME TO WINDROSE CHIROPRACTIC
WELCOME TO WINDROSE CHIROPRACTIC Please complete the following information. We appreciate your cooperation! Chiropractic Case History/Patient Information (Please print) Date: Patient # Doctor Name: Social
More informationBenchMark Rehab Partners
BenchMark Rehab Partners Welcome to Patient Name: Patient #: Date: At BenchMark Rehab Partners we believe communication is essential to achieving the best possible patient outcomes. Understanding your
More informationPHYSICAL THERAPY CENTRAL
PHYSICAL THERAPY CENTRAL PATIENT INFORMATION Patient Name: Address: City: State: Zip: Employer: Birthdate: Age: Home Phone: Cell Phone: Work Phone: Preferred Contact Method for Appointment Reminders: Home
More informationPRINT CLEARLY. Name: (first) (last) (m.i) Address: City: State: Zip:
PRINT CLEARLY NEW PATIENT FORM Name: (first) (last) (m.i) Address: City: State: Zip: Email: Sex: Male Female Student Yes No Home Ph: Cell Ph: Work Ph: Fax: Age: Of Birth: Statement Preference: E-mail Fax
More informationDate. D Light D Moderate D Strenuous
FAMILY CHIROPRACTIC CARE PATIENT HEALTH QUESTIONNAIRE Patient Name What type of regular exercise do you perform? D None Date D Light D Moderate D Strenuous What are your overall health goals? D Weight
More informationCity: State: Zip: Home ( ) Cell ( ) Work ( ) Who Referred You? Phone ( ) Address: City: State: Zip:
Today s : First Name: M.I. Last Name: Address: City: State: Zip: Apt Home ( ) Cell ( ) Work ( ) Email: of Birth: Marital Status: S M D W Sex: F / M Social Security # - - Who Referred You? Phone ( ) Address:
More informationWelcome to Phillips Family Chiropractic
Welcome to Phillips Family Chiropractic Name: Age: DOB: / / SS# / / Address: City: State: Zip Code: Phone: ( ) - Employer: Occupation: Circle One: Single / Married Number of Children: Email: Spouse: Employer:
More informationRD Physical Therapy & Wellness, LLC
RD Physical Therapy & Wellness, LLC Tel: 443-253-4603 Fax: 410-720-2690 Clinic Location : 3450 Ellicott Center Dr., Suite 105 Ellicott City, MD 21043 Patient information: Registration Form Last name: First
More informationBody Basics Physical Therapy Medical History
Body Basics Physical Therapy Medical History Name Date Age Height Weight Hand Dominance: Right/Left How did you hear about us? Doctor s First and Last Name: Office location: Describe the pain or problem(s)
More informationPatient Name: Male Female Married Divorced Widowed Single. SSN: Date of birth: Address: Phone: (home) (cell) (other) Emergency contact name:
Patient Information: Patient : Male Female Married Divorced Widowed Single SSN: of birth: Address: Phone: (home) (cell) (other) Emergency contact name: Relationship to patient: Emergency contact phone:
More informationDear Valued Patient, Your Insurance Card A Picture ID Any disks with MRI, CT Scans, or Xray images
J. Lex Kenerly, III, M.D. Orthopaedic Surgeon J. Matthew Valosen, M.D. Orthopaedic Surgeon Amber Aragon, M.D. Orthopaedic Surgeon Monica Carrion-Jones, M.D. Physical Medicine and Rehabilitation W. Scott
More informationPatient Information. Insurance Information Who is responsible for this account? Relationship to Patient. Insurance Co: Member ID:
Patient Information Today s Date: Birth Date: SS#: First Name: M. I.: Last Name: Address: City: State: Zip: Sex: M F Age: Email: Cell: ( ) Home: ( ) Emergency Contact: Relationship: Cell: ( ) Home: ( )
More informationACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE
WELCOME to our office! Please allow our staff to make a photocopy of your insurance card(s) (if applicable). Please Print Clearly PERSONAL INFORMATION: Patient Name: Preferred Name: Address: City/State/Zip:
More informationPATIENT /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):
More informationPatient Registration Form
PATIENT INFORMATION Patient Name: of Birth: Age: Marital Status: Married Single Home Phone: Email: Address: Cell: SS#: Divorced Patient Registration Form Account Number: Gender: Widowed Separated Unknown
More informationBrannon Family Chiropractic 197 East Brannon Road Nicholasville, KY (859) (Phone) (859) (fax)
Brannon Family Chiropractic 197 East Brannon Road Nicholasville, KY 40356 (859) 971-0370 (Phone) (859) 971-0650 (fax) Patient Information Date: Social Security # Patient Name: Address: City: State: Zip:
More informationTracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: / / Age: Sex: M F Social Security #: / / Marital Status (circle
More information(Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION. If not, what is your legal name? (Former name): Birth date:
Today s date: (Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION Last name: First: MI: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your
More informationDemographic Information
Demographic Information Patient Name: Mailing Address: City: State: Zip Code: Home Phone: OK to Leave Message: Brief Extended Cell Phone: OK to Leave Message: Brief Extended Work Phone: OK to Leave Message:
More informationThank you again for choosing CrossRoads for your care. We hope to exceed your expectations.
BELIEVE! COMMIT! ACHIEVE Dear New Patient, The staff at CrossRoads Physical Therapy and I are delighted that you have chosen our facility for your therapy. Our goal is to provide you with a premium level
More informationPlease Be Aware. Patient Signature: Date: (Signed by Parent or Guardian if under age 18 or dependent)
Personal Information (Please Print, Preferably Black Ink) Name: Date of Birth: Today s Date: Address: City: State: ZIP: Cell Phone: Home Phone: Work Phone: Email: Occupation: Employer Name: Emergency Contact
More informationHun Chiropractic 1 Creekview Ct, Suite B Greenville, SC P: F:
1 Creekview Ct, Suite B Greenville, SC 29615 Personal Information Last Name: First Name: Middle Initial: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: Age: Social
More informationPatient Information TO BE COMPLETED BY PARENT/GUARDIAN ACCIDENT INFORMATION. Date SSN/HIC/Patient ID # Patient Name
1 Date SSN/HIC/Patient ID # Patient Name Address PATIENT INFORMATION Best time/place to contact you? E-mail Sex M F Age Date of Birth Married Widowed Single Separated Divorced Minor Patient Employer/School
More informationHave you had Chiropractic Care Before? When? Where? What is your current complaint (be specific)?
Welcome to Rizzo Chiropractic Holistic Health and Wellness Center Check the following services you are interested in: Chiropractic Physical Rehabilitation Nutritional Analysis (Hair, Blood & Urine) Detox
More informationM F Last Name First Name Middle Initial Gender. Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different):
Welcome to Patient Information: Date of Birth: M F Last Name First Name Middle Initial Gender Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different): Employer: Occupation:
More informationMedical Information Sheet
Please use this guide as a tool to identify where you want to head with your recovery and identify areas or pieces that may be missing in your wellness. Simply check the answers that best apply to you
More informationBefore your first visit there are a few things we would like you to be aware of:
I would like to personally thank you for choosing us to serve you for your physical therapy needs. Our team takes pride in offering a professional and friendly environment for you to rehabilitate. Our
More informationuqua 6560 Greenback Lane, Citrus Heights, CA (916) Fax (916)
NOTICE OF PATIENT INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION PLEASE REVIEW IT CAREFULLY FUQUA PHYSICAL
More information