Physical Therapy Patient Attestation Form

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10/30/2015
Patient Attestation
PATIENT ATTESTATION FORM
1. Legal Full Name
(Please Print or Type)
First
Middle
Last
Suffix or Maiden
Address
City
State
Zip Code
Contact Phone Number
Alternate Phone Number
(
)
(
)
Email address:
2. Patient Information
Patient’s chief complaint (why patient is seeking physical therapy care)
Please Check One Below:
a)
I am not under the care of a doctor of medicine, osteopathy, chiropractic, podiatry, dental
surgery, licensed nurse practitioner, or licensed physician assistant for the chief complaint
listed on this form and wish to seek physical therapy care at this time.
b)
I am under the care of a doctor of medicine, osteopathy, chiropractic, podiatry, dental
surgery, licensed nurse practitioner, or licensed physician assistant for the chief complaint
listed on this form and wish to seek physical therapy care at this time. The Practitioner
identified on this form will be provided a copy of the initial evaluation and a copy of patient
history obtained by the physical therapist within 14 days. (Fill out section 3 below)
3. Practitioner of Record.
If after receiving physical therapy care for 30 calendar days for the condition for which I sought
treatment does not improve, I intend to seek further treatment and evaluation from the practitioner
listed below. Additionally, I consent to the release of my personal health and treatment records to
the listed practitioner.
Practitioner’s Full Name & Address:
Practitioner’s Contact Phone Number’s:
Office (
)
Fax
(
)
Email:
Date
Signature of Patient

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