PATIENT INTAKE FORM

REFERRAL INFORMATION

 

During this calendar year (2018), have you had any of the following Rehabilitation Services?

INSURANCE INFORMATION

 

CONFIDENTIAL PATIENT INFORMATION

Personal health history
General current conditions

(Please read all and check all that apply to you)
Recent
Diagnosed Condition
Specific Body Pain
Specific Current Conditions
0
1
2
3
4
5
6
7
8
9
10
Where's the problem? Select items that apply to you

PHYSICAL THERAPY ATTENDANCE POLICY

Cancellation and Missed Appointment Policy

I have read, understand, and agree to follow the above Cancellation and Missed Appointment Policy.

CONSENT TO EVALUATE AND TREAT

I hereby request and consent to the performance of various modes of physical therapy on me (or the patient named below, for who I am legally responsible) by Superior Physical Therapy and/or other licensed physical therapists working at the clinic. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatments. I intend this consent form to cover the entire course of treatment of my present condition and for any future condition(s) for which I seek treatment. I understand that I may refuse treatment at any time and that I am responsible for my healthcare choices.

OUR PRIVACY POLICY

The office of Superior Physical Therapy is committed to upholding the security and confidentiality of personal information that you provide to us. We take responsibility of safeguarding your information very seriously. We do not share or sell patient information with anyone outside our office without your written consent. This policy covers information including personal, financial, or health information about a consumer or customer relationship.

I have been given a copy of the privacy policy of Superior Physical Therapy. I hereby authorize that my records of evaluation and treatment with the office of Superior Physical Therapy may be forwarded to referring physicians, specialists, or therapists, who are also involved in my healthcare. Your insurance claims will be transmitted through an electronic clearing house, in accordance with HIPPA regulations.

By agreeing below, I have read, or have had read to me, the above consent to evaluation and treatment statement, that I am aware of the privacy policy, and that I certify that my medical information above is correct to the best of my knowledge.

For Office Use Only