Patient Resources

Patient Resources

Request an Appointment

New Client Form

Download and complete this form prior to your appointment, or complete it electronically below.

DOWNLOAD FILE

New Client Form

Patient Name

DOB

Age

SSN

Gender

Marital Status

Address

City/State/Zip

Phone Number

Employer

Employer Phone Number

Employer Address

City/State/Zip

Emergency Contact/Representative

Phone Number

Referring Physician

Primary Care Physician

Onset Date (injury, accident, surgery date or recent date symptoms started)

Primary Insurance Company

Secondary Insurance Company

Work Comp/Auto Company

Claim Number

Is this related to a work injury?

Yes

Is this related to a car accident?

Yes

Medicare Part B Beneficiaries Only: Are you currently receiving home health care services?

Yes

Medicare Part B Beneficiaries Only: Have you received rehabilitative services in the last calendar year?

Yes

Consent to Therapy

1. I have presented myself to this facility for therapy treatments and consent to diagnostic procedures and care provided by my attending therapist.

2. I give authorization to be treated within the therapy clinic areas not totally private of other patients/personnel.

3. I understand that if I do not attend therapy for two weeks or miss three consecutive appointments that I am subject to discharge. Once I have been discharged I understand that I will need new physician’s order/referral for any further therapy and will be receiving a new evaluation.

4. I hereby authorize the release of medical information necessary to process my insurance and authorize payment directly to the provider of service and FULLY UNDERSTAND THAT I AM FINACIALLY RESPONSIBLE for any services not covered by this authorization. **WORKERS COMPENSATION** I hereby authorize my rehab consultant to receive my records related to my work injury.

5. I have reviewed the HIPPA Privacy Policy.

I have read and fully understand the above consent form and any questions I had have been answered to my satisfaction.

Patient/Representative Signature

Date

Insurance

Most insurances accepted. Contact us for more information.