Mickey Mayer Physical Therapy - New Patient Registration

Patient Name* This field is required.

First Name

Middle Name

Last Name

Date of Birth* This field is required.mm/dd/yyyy

Sex* This field is required.

Address:* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

Responsible Parent/Guardian (if patient is a minor)

First Name

Middle Name

Last Name

Phone Number* This field is required.

Area Code

Phone Number

example@example.com

Marital Status

Primary Care Physician* This field is required.

Name of Primary Insurance* This field is required.

Policy Holder* This field is required.

Name of Secondary Insurance (if applicable)

Emergency Contact:

First Name

Last Name

Phone Number

Area Code

Phone Number

Relationship to Patient

How did you learn of our practice?

Brief Health Summary (Check all that apply)* This field is required.

N/A

Ankle Pain

Arthritis

Back Pain

Chest Pain

Constipation

Depression

Diarrhea

Dizziness

Fainting

Fatigue

Fever

Fracture

Headaches

Pain in Hand

Heartburn

Heart Problem

Knee Pain

Loss of Balance

Low Back Pain

Menstrual Irregularity

Menstrual Pain

Muscle Stiffness

Muscle Weakness

Neck Pain

Neck Stiffness

Pain in Fingers

Pain in Joints

Pain in Wrist

Pins & Needles in Arms/Hands

Pins & Needles in Legs/Feet

Shoulder Pain

Sprain

Stomach Pain

Tension

Trouble Sleeping

Trouble Urinating

Trouble Walking

Other

Insurance Assignment and Release

I certify that I have insurance coverage with name of insurance company * and assign directly to Michal Mayer, DPT and Michal Mayer Physical Therapy all insurance benefits. I understand that I am financially responsible for all charges by Michal Mayer, DPT and/or Michal Mayer Physical Therapy whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Medicare/Mediap Authorization

I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made on my behalf to Michal Mayer, DPT and/or Michal Mayer Physical Therapy for any services furnished to me by that provider.

Informed Consent to Physical Therapy Care

Please discuss any questions or concerns with the Physical Therapist before signing this consent.

I hereby request and consent to the performance of physical therapy treatment including various modes of physical therapy by the physical therapist and his/her staff
I have had the opportunity to discuss with the physical therapist and/or with other office personnel the purpose and benefits of the physical therapy treatment. Possible alternatives have been reviewed to my satisfaction.
Though physical therapy treatments are usually beneficial and seldom cause any harm or problem, I understand and am informed that there are some risks to treatment.
I understand that I will be receiving some or all of the following treatment: Physical therapy evaluation and assessment, physical therapy re-evaluation, electrical stimulation, ultrasound, therapeutic exercises, neuro-muscular re-education, ambulation training, therapeutic massage, manual therapy techniques, therapeutic activities and/or various other tests and performance evaluations.
I understand that Physical Therapy is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee has been expressed or implied by anyone regarding the physical therapy treatment that I have requested and authorized. I have had the opportunity to read the form and ask questions. My questions have been answered to my satisfaction.
I consent to the proposed treatment.

My signature below affirms the above:* This field is required.

Clear

Printed Name of Beneficiary, Guardian, or Personal Representative

Date* This field is required.

Date

Authorization To Share Medical Information and HIPAA Policy

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation.

This office conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at the front desk. Please check to indicate you have been made aware of its availability: * This field is required.

Yes

My signature below affirms all the statements above and consents to all listed above:* This field is required.

Clear

Printed Name of Beneficiary, Guardian, or Personal Representative* This field is required.

Date* This field is required.

Date

Mickey Mayer Physical Therapy - New Patient Registration