Patient Intake Form printable pdf download

PATIENT INTAKE FORM

PLEASE FILL OUT COMPLETELY AND CLEARLY

Date:

Patient’s Legal Name:

Nickname:

[ ] Male [ ] Female DOB:

SSN:

Mailing Address:

City/State/Zip:

Main Phone:

Cell:

Address:

Primary Insurance:

Secondary Insurance:

Primary Insured Name:

Relationship to patient:

Primary Insured DOB:

Primary Insured SSN:

Primary Insured Mailing Address (if different from the above):

Date of Injury:_______________________________ Claim #:_____________________________________________________

Insurance Company:_______________________________________________ Phone #:_______________________________

Address:_________________________________________________________ State:_________ Zip:____________________

Adjuster/Case Manager:___________________________________________________________________________________

Is an attorney involved? [ ] Yes [ ] No - Attorney Name/Phone#:_________________________________________________

Employer:

Occupation:

Address:

Phone#:

Medicaid Patients: Who is your Passport Provider:

Date of last visit:

Have you had any of these therapies in the past year? [ ] PT [ ] OT [ ] Speech [ ] Chiropractic [ ] Cardiac/Pulmonary or [ ] No

If yes, when was it?_________ How many?______ Was it at our clinic [ ] Yes [ ] No Was it for the same injury? [ ] Yes [ ] No

Referring Physician:

Phone:

Emergency Contact:

Phone:

Relationship:

Please sign below to acknowledge that the above information is accurate, that you have received the HIPAA Notice of Privacy

Practices handout, and to authorize our clinic to treat for physical therapy.

Signature of Patient:

Date:

Information below is required for treatment of a minor or a patient who does not have their own power of attorney.

Name of Parent or Legal Guardian:

Signature:

[ ] I would like to receive appointment reminders via email.

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Patient Intake Form

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