Before your first visit there are a few things we would like you to be aware of:

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1 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 goal is to create a safe and comfortable environment for all to heal using the most up-to-date and advanced treatment techniques to provide a quick recovery. If you have any questions in regards to physical therapy one of our licensed therapists would be happy to speak with you. Please call the front desk to arrange this. Billing questions can be addressed to Judy at (810) Before your first visit there are a few things we would like you to be aware of: If you are coming to be evaluated for the neck or shoulders please consider a tank top or sports bra so we have access to your shoulder and neck. If you are coming to be evaluated for low back, hips, knees, or feet please bring loose fitting shorts (If you do not have them, we can provide them for you). The first visit will last about an hour and will include a thorough examination, a computer survey, and in many cases exercise to be done at home. A physical therapy program may last 4-6 weeks depending on you needs, so bring your calendar to set up your appointments. Remember your prescription for physical therapy if you have one, an updated health history form, current medication list, your insurance card and a current ID. Please arrive 15 minutes early. We look forward to working with you to achieve your goals, Markus Munger PT, Cred. MDT Clinton Township Morley Drive Clinton Township, MI Fort Gratiot th Ave. Suite 1 Fort Gratiot, MI

2 First Name: MI: Last Name: Date: Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) SS#: Address: How did you hear about us? Date of Birth: Age: Sex: M F Marital Status: S M D W Have you had therapy before? Yes No if yes, Describe: Have you received Home Care in the last year? Yes No if yes, Date of Discharge: Update by Yes No Emergency Contact: ( ) Name: Date of injury or onset: Cause of injury: Injury Area: Physicians Name: Phone: ( ) Last seen: Physicians Address: Responsible Party: Relationship: Address: City: Phone: ( ) Employer: Occupation: Employer Address: Employer Phone: ( ) Ins. Holders Name: Birth date: SS#: Primary Insurance: Insured Name: Group #: ID#: Address: City: State: Zip: Phone: ( ) Insured Employer: Relationship to insured: Insured D.O.B: Sex: M F Secondary Insurance: Insured Name: Group #: ID#: Address: City: State: Zip: Phone: ( ) Insured Employer: Relationship to insured: D.O.B of insured: Sex: M F

3 Patient Name: Date of Birth: Do you have or have you ever had any of the following conditions? (Check all that apply) Pregnant Currently Pregnant Arthritis Cancer Visual Impairments Heart Condition Congestive Heart Failure Heart Attack Atherosclerotic Disease / CAD Angioplasty Valvular Disease Stents Arrhythmia Coronary Artery Bypass Graft Angina Pacemaker Stroke Peripheral Artery Disease High Blood Pressure Low Blood Pressure Thyroid Problems Diabetes Depression Dizziness/Fainting Fractures Headaches Hepatitis/HIV/AIDS Kidney Problems Prior Surgeries Recent Pneumonia Neurological diseases Back pain Osteoporosis Anxiety or Panic Attacks Kidney problems Incontinence Respiratory Problems Asthma COPD Emphysema Bronchitis Seizures Allergies: If checked any above, explain: What specific activities are you having difficulty with? What are the personal goals you hope to achieve from therapy? Have you had prior physical/occupational therapy for this condition? What was done, what were the results? YES NO

4 Patient Name: Date of Birth: Please Initial Each as Applicable: CONSENT TO TREATMENT: I consent to rehabilitation and related services at Munger Physical Therapy. In so doing, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching, and/or direct contact of sensitive nature. TREATMENT OF MINORS: I, as a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so. LIABILITY: I know and agree that Munger Physical Therapy is not responsible for loss or damage to personal valuables. WAIVER AND RELEASE: I hereby release, discharge and acquit Munger Physical Therapy, it s agents, representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services. AUTHORIZATION OF PAYMENT: I hereby assign all benefits directly to Munger Physical Therapy and also authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice and Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the service I receive, I will be financially responsible for payment. NOTICE OF PRIVACY: I acknowledge receipt of Notice of Privacy Practices. I certify that all of the information provided herein is true and correct. Patient/Guardian Signature Date: Witness Signature Date:

5 Notice of Privacy Practices This is summary describes how we use and share information about you. This summary also describes how you may see and get copies of this information. We might use or share information about you for Treatment- Such as when our Physical Therapist discusses your care. Payment- Such as when we bill your insurance company for services provided to you. Operations- Such as when we work to make the quality of care we provide better. When we share information to protect the health and safety of others or you or when we respond to court requests. We also may send you appointment reminders. How you may see and get copies of this information You have the right to: 1. Ask for restrictions on the way we use and give out your information. However, we are not required to do what you ask. 2. Obtain and inspect a copy of your health record. 3. Add information to your health record. 4. Ask that your health information be sent to alternate address or that you be called at an alternate phone number. 5. Change your mind if you told us we could use or share your information for reasons other than those listed above. 6. Get a list of the dates we gave out your information. It will be a list of the dates that the law requires us to keep a record of giving out your information. Our Commitment to Respect Privacy Munger Physical Therapy is required to: 1. Keep your information private. 2. Let you know if we cannot do what you have asked us to do with your information. 3. Try to reach you at another location or phone number, if you ask us to do so. 4. Use and/or give out your information as listed above and as the law permits, unless we have your permission to do more. 5. As we serve our patients, we may change what we do with your information. If we make changes, we will give you a new notice the next time you visit us. Complaints If you believe that your privacy rights have been violated, please contact our privacy officer. Munger Physical Therapy Attn: Privacy Officer th Ave, Suite 1 Fort Gratiot, MI jim@mungerpt.com and/or markus@mungerpt.com

6 Medication List Patient Name: Birth Date: Date: Name of Medication Dosage How Administred When to take Why take it? Physician Over-the-counter Medications (Check all that applies) Allergy relief, Antihistamines Antacids Diet Pills Cold / Cough Medication Laxatives Sleeping Pills Asprin / Other relief for pain Multivitamin Others: Patient Signature: Reviewed By:

7 Cancellation/No Show Policy Cancellations need to be telephoned in by 5 PM the previous day before scheduled appointment. Failure to show for appointments will be charged a $30.00 no show fee that will be the patient s responsibility. This policy is being put into place due to frequent cancellations and no shows. These appointments then cannot be filled by patients who are in need of our services. Thank you in advance for your cooperation. Signature Date Printed Name