Is a 3 rd party settlement anticipated (lawsuit, auto accident, etc)? Yes No
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- Jeffry Fleming
- 5 years ago
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1 PATIENT INFORMATION Patient Name Date of Birth Home Address Soc. Sec. No. Home Phone Work Phone Cell Phone Physician Date of Surgery Date of injury/flare up Cause Date of next Dr. appt. Referred to Ultrahealth by Is a 3 rd party settlement anticipated (lawsuit, auto accident, etc)? Yes No EMPLOYER INFORMATION LEGAL INFORMATION (if lawsuit) Name Attorney Address Address Phone Phone IN CASE OF EMERGENCY CONTACT: Name Home Phone Work Phone TODAY S DATE
2 PATIENT HISTORY Name: Sex: Date of Birth: Please complete all requested information. 1. Have you ever had? (If yes, please explain) High blood pressure No Yes Heart or Circulation Disorders No Yes Seizures No Yes Dizzy Spells No Yes Diabetes No Yes History of Smoking No Yes Cancer No Yes Arthritis/Osteoarthritis No Yes Osteoporosis No Yes Immune Deficiency Disease No Yes Other No Yes 2. Please list surgeries you have had; please give procedures and dates if possible: 3. Please list recent diagnostic studies (Cat-scan, MRI, X-rays): 4. Do you have any METAL anywhere in your body; pins/plates post-fracture, or pacemaker (other than teeth)? N Y Describe: 5. (For women only)are you currently pregnant? N Y Date of last menstrual cycle: 6. Do you have any abnormal trouble with vision? N Y /Hearing? N Y 7. List any allergies you have: 8. Have you ever taken steroids/anti-coagulants for an extended period of time? N Y 9. Have you had any unusual weight gain or loss lately? N Y 10. List medications you are now taking: 11. Have you ever had physical therapy treatments before? N Y If yes, please indicate where, when, and for what problem: 12. Describe briefly the history of your present ACCIDENT, INJURY, OR ILLNESS: Onset date: description:
3 LATE CANCELLATION POLICY Please understand that missed appointments are an impact to the clinic and to the availability of the therapist s time for other patients. Also it is very important to show up to your appointment on time. You will be charged $60 for a missed or too late to be seen appointment as well as a cancellation without 24 hours notification. This charge must be paid by you.- Your insurance will not cover charges for missed appointments. Patients Signature: Date:
4 PATIENT POLICY SHEET Welcome to ULTRAHEALTH Physical Therapy. Our goal is to provide quality patient care as efficiently as possible. To this end, we have established the following policies and billing plans. Therapy is provided on an appointment basis only. We ask that you contact us if you will be late and we require 24 hour notice if you must cancel an appointment. We ask that you always inform your therapist of any upcoming doctor s appointments (if you have an attending physician). Please read the following billing options carefully and select one: PLAN A You will be billed directly for all charges. $150 is due today, and thereafter you will be billed monthly. You will be responsible for filing claims with your insurance company although we will be happy to assist you in any way we can. PLAN B As a convenience to you, ULTRAHEALTH will bill your insurance company directly. You will be required to provide insurance information at the front desk and pay a $80 deposit before leaving the office today. The deposit will be applied to charges not paid in full by your insurance carrier. Any remaining balance will be refunded to you. Please note that you are still responsible for payment of all charges incurred at ULTRAHEALTH. If your insurance company makes only a partial payment for charges incurred, you will be billed for the remaining balance after deducting your deposit. If your insurance company fails to make any payment within 90 days, all charges will become due and payable by you. PLAN C If this is a work related injury and you are covered by workman s compensation insurance, we will file all claims and accept assignment for payment. You must provide us with complete billing information. PLAN D If you belong to a health plan contracted with ULTRAHEALTH, we will file all forms and accept assignment for payment. You are responsible for any co-payment at the time of service. You are also responsible for verifying your own eligibility and coverage at ULTRAHEALTH. Please note: Any charges not specifically covered by your health plan (for any reason), are your responsibility. You will be billed accordingly. Check one: PLAN A PLAN B PLAN C PLAN D Signature Date
5 OTHER PHYSICAL THERAPY SERVICES Have you received physical therapy or rehabilitation for this or a similar injury/condition at any other time: No Yes Please list below approximate dates and name of clinic. DATE CLINIC INJURY Signature Date
6 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. ULTRAHEALTH, INC. s LEGAL DUTY ULTRAHEALTH, INC., is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein. USES AND DISCLOSURES OF HEALTH INFORMATION ULTRAHEALTH, INC., uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, ULTRAHEALTH, INC., may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you. ULTRAHEALTH, INC., may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. In any other situation, ULTRAHEALTH, INC. s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. ULTRAHEALTH, INC., may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. PATIENT S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. ULTRAHEALTH, INC., will consider all such requests on a case by case basis, but the practice is not legally required to accept them. CONCERNS AND COMPLAINTS If you are concerned that ULTRAHEALTH, INC., may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on ULTRAHEALTH, INC. s health information practices or if you have a complaint, please contact the following person: ULTRAHEALTH, INC. Office Administrator 220 Bush St., Suite 110, San Francisco, CA Telephone: Fax:
7 ULTRAHEALTH, INC. PATIENT INFORMATION ACKNOWLEDGEMENT FORM I have read and fully understand ULTRAHEALTH, INC. s Notice of Information Practices. I understand that ULTRAHEALTH, INC., may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that ULTRAHEALTH, INC., will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions. I hereby acknowledge to the use and disclosure of my personal health information for purposes as noted in ULTRAHEALTH, INC. s Notice of Information practices. I understand that I retain the right to revoke this acknowledgement by notifying the practice in writing at any time. Patient Name Signature Date
uqua 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
Medical 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
New 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
Agape 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
PATIENT REGISTRATION
7521 Virginia Oaks Drive #240 Gainesville, VA 20155 Ph: 703-753-7600 PATIENT NAME (FIRST, MIDDLE, LAST) PATIENT REGISTRATION DATE: HOME PHONE HOME ADDRESS CELL PHONE CITY STATE ZIP CODE SOCIAL SECURITY
REASON FOR TODAYS VISIT Is this injury / condition related to your..
DATE: PATIENT INFORMATION Patient Name: First Middle Last Male Female Address: City: State: Zip: Home phone: Cell: Date of Birth: Marital Status: married single other Soc Sec #: Drivers Lic. # Email Address:
For your convenience, please schedule your appointments two weeks in advance.
Welcome! Welcome to Rebound Physical Therapy. We are pleased you have selected us for your physical therapy services. We will bring you back to a healthy functional and recreational level and educate you
New Patient Intake Paperwork
New Patient Intake Paperwork NAME: Last First Middle DATE OF BIRTH: SEX: M / F ADDRESS: Street City State Zip PHONE: MOBILE: EMAIL ADDRESS: EMPLOYER NAME: PHONE: EMPLOYER ADDRESS: EMERGENCY CONTACT: PHONE:
Registration 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
4) 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):
Physical Therapy Services of Ottawa County Patient Registration Form
Physical Therapy Services of Ottawa County Patient Registration Form Personal Information Name Age Sex Date of birth Single Married Widowed Address City State Zip Home phone Cell phone Work phone Email
PRINT 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
City: 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
Current 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
RD Physical Therapy & Wellness, LLC
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Informed Consent for Physical Therapy Services
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Patient 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
Please 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
New patient intake information
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AVIDAPT avidapt.com
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4) 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):
920 NE 112 th Avenue, Suite 103, Vancouver, WA Phone: Fax:
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Patient Name: Male Female Married Divorced Widowed Single. SSN: Date of birth: Address: Phone: (home) (cell) (other) Emergency contact name:
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Patient Registration & Health History
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Advanced PT, LLC 200 W Douglas Ave, Ste 1040 Wichita, KS (866)
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Medical 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
Patient name: LAST FIRST MIDDLE. Address: Responsible Party SS#: Required If patient a minor and/or full-time student. Employer: Occupation:
PATIENT Information SHEET ACCT # PT Patient name: LAST FIRST MIDDLE Date of Birth: Age: (please circle :) Female Male Address: Responsible Party SS#: Required If patient a minor and/or full-time student
Tracy 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
Worker s Compensation Intake Form
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All Care Physical Therapy Center Directions: Please fill in all spaces, if not applicable, please put N/A.
General Information Name: All Care Physical Therapy Center Directions: Please fill in all spaces, if not applicable, please put N/A. Home Phone: Email: SSN: Cell Phone: Gender: Female Male Other Marital
HEALTH 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
Stat or Routine Exam / Procedure: Chart # Date of Exam: Age: Sex: Date of Birth: Patient s Name: Referring Physician:
Memorial MRI and Diagnostic Stat or Routine Exam / Procedure: Chart # Date of Exam: Age: Sex: Date of Birth: Patient s Name: Referring Physician: X-Ray / IVP, CT Scan, and Ultrasound: Patient History Have
Personal Insurance Intake Form
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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
Patient Information Patient Info. Update
Medical History Brian R. Carr, D.D.S., M.D Patient Information Gagandeep Pandher,D.D.S. Patient Info. Update Date Date Initials Date Initials Name Address Cell Phone # City State Zip Work # Date of Birth
PATIENT INFORMATION. Name Soc. Sec. # - - Last Name First Name Initial Address. City State Zip code. E mail address Sex M F Age Birth date
PATIENT INFORMATION Name Soc. Sec. # - - Last Name First Name Initial Address City State Zip code E mail address Sex M F Age Birth date Home phone Mobile phone Work phone In case of emergency who should
PATIENT INFORMATION Patient Demographics and Insurance
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Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
WELCOME TO OUR OFFICE
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Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
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Professional Sports & Orthopaedic Rehabilitation Associates, LLC
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Insurance Information
New Patient Registration - Brunswick Physical Therapy, PLLC Patient Name: DOB: M[ ] F[ ] Social Security # (last 4 digits): [ ]Single [ ]Married [ ]Widowed [ ]Other Address: City: State: Zip Code: Home
PREPARATION FOR YOUR APPOINTMENT
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Patient/Guardian Signature: I hereby agree that the information above is true and accurate. Patient Medical History Form PATIENT MEDICAL HISTORY FORM
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Patient Information. Patient Name: (Last, First, MI) DOB: / / Home address: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) -
Patient Information Patient Name: (Last, First, MI) DOB: / / Home address: Mailing address: (if diff) Email Address: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Employer: Employer Phone: ( )
Patient Information TO BE COMPLETED BY PARENT/GUARDIAN ACCIDENT INFORMATION. Date SSN/HIC/Patient ID # Patient Name
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221 Madison Ave Morristown, New Jersey (973) Fax (973) PATIENT INFORMATION. Mailing Address: City: State: Zip: Birth Date:
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NEW PATIENT INFORMATION FORM
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NEW PATIENT CHECKLIST
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PATIENT 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
HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN (317)
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(Formerly AFCN Physical Medicine) A member of the Arkansas Family Care Network, P.A.
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SHEDDON PHYSIOTHERAPY AND SPORTS CLINIC
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EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE
DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# email Sex Marital Status Employer If Student, what school? Spouse s Name Who may we
PATIENT INFORMATION. Child s Name: DOB: Address: Phone: Zip: School: Emergency Contact: Phone: Relationship to Patient:
PATIENT INFORMATION Child s Name: DOB: Address: Phone: Zip: School: Father s Name: Occupation: Phone: (work) Email Address: Mother s Name: Occupation: Phone: (work) Email Address: DOB: Social Security
PHYSICAL THERAPY CENTRAL
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Before 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
Physical Therapy with care and knowledge
Patient Demographic Information Last Name: First Name: Middle Initial: Address: City: State: Zip: Primary Phone: Secondary Phone: D.O.B: Social Security: Driver s License Number: May we leave a message?
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: Weight: Mailing Address:
PERSONAL INFORMATION PATIENT INFORMATION Last Name: _ First Name: _ Middle : Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: _ Weight: Mailing Address: City: State: Zip: Social Security #:
CHIROPRACTIC PATIENT REGISTRATION AND HISTORY
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Multi-Specialty Musculoskeletal Pain Relief Center
Name Social Security # Age Birthdate Date Home Tel Address City State Zip Work Tel Cell Number Email Address Marital Status: M S W D # Children Spouse s Name Your Occupation Emergency Contact Name and
PRO SPORTS THERAPY, INC. (P.S.T.)
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Who to call for an emergency: Name: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Relationship:
Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one) Married/Single/Divorced/Widow Address: Zip Code: Home Phone: ( ) - E-mail Address: Cell Phone:
ACIC 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
P: F:
PATIET IFORMATIO FORM Patient Information Last ame First ame SS Date of Birth Gender Marital Status Address City State Zip Home Phone # Work Phone # Cell Phone # Email Emergency Contact Last ame First
PATIENT INFORMATION. Today's Date: (PLEASE PRINT) Soc. Sec.# - -
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PATIENT INFORMATION. Street address: Social Security no.: Home phone no.: ( ) City: State: ZIP Code:
Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Married / Divorced / Separated / Widow Is this your legal name? If not, what
CENTERS FOR HEALTHY LIVING
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Patient Health Questionnaire
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Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757
Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757 PLEASE PRINT Patient Name SS# Address City State Zip Code Birth Date / / Age Circle one: Marital Status: S/M/D/W/P How
Chiropractic Case History/Patient Information
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Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ
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