Patient Demographic Information
Name
*
First Name
Middle Initial
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Last 4 # of SSN
Employment Status
FT
PT
None
Retired
Student
Other
Sex
*
M
F
Marital Status
Single
Married
Other
Home Phone
Mobile Phone
*
Email
*
Appointment Reminder Contact Method (check all that may apply)
Text
Mobile
Email
Home Phone
No Appointment Reminder
Employer Information
Employer
Employer Phone Number
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Emergency Contact Information
Emergency Contact Name
*
Emergency Contact Phone Number
*
Relationship to Emergency Contact
*
Physician Information
Referring Physician
Referring Physician Phone
Referring Physician Fax
Primary Physician
Primary Physician Phone
Primary Physician Fax
Additional Questions
Injury / Onset Date
-
Month
-
Day
Year
State Where Injury Occurred
Surgery Date
-
Month
-
Day
Year
Body part / DX, Right or Left
Post - Surgical
Yes
No
Work Related
*
Yes
No
Accident Related
*
Yes
No
Auto Related
*
Yes
No
Attorney Involved
Yes
No
Adjuster/Nurse Cases Mgr
Adjuster/Nurse Cases Mgr Phone
Attorney
Attorney Phone
Are you a Veteran?
*
Yes
No
The entire team here at Prosthetic Orthotic Solutions International thanks you for your service!
How did you hear about us?
Additional Questions
Are you currently receiving outpatient physical therapy?
Yes
No
Outpatient Physical Therapy Company Name
*
Outpatient Physical Therapy Primary Therapist Name
*
Are you currently residing in a Skilled Nursing Facility?
Yes
No
Name of Skilled Nursing Facility
*
Primary Insurance Section
Primary Insurance/Plan
*
Primary Insurance Policy ID #
*
Primary Insurance Group #
Primary Insurance Phone
Are you the primary insurance policy holder?
*
Yes
No
Primary Insurance Card Holder Name
*
Primary Insurance Card Holder DOB
*
Relationship to Policy Holder of Primary Insurance
*
Self
Spouse
Child
Other
Secondary Insurance Section
Do you have secondary insurance?
*
Yes
No
Secondary Insurance/Plan
*
Secondary Insurance Policy ID #
*
Secondary Insurance Group #
Secondary Insurance Phone
Are you the secondary insurance policy holder?
*
Yes
No
Secondary Insurance Card Holder Name
*
Secondary Insurance Card Holder Date of Birth
*
-
Month
-
Day
Year
Relationship to Policy Holder of Secondary Insurance
*
Self
Spouse
Child
Other
Initials of Authorized Party
*
Patient, please initial here if the above information is correct and complete.
Date
*
-
Month
-
Day
Year
***Office Staff use ONLY***
Patient Service Specialist will initial next to each task below once completed.
Intake Completed By
Intake Date
-
Month
-
Day
Year
Registered By
Registration Date
Date Eval Scheduled
-
Month
-
Day
Year
Account Number
Billing Disclosure added in OPIE
Completed
Verified & CopiedDL/Photo ID
Completed
Consent to receive calls and/or text messages, reviewed with patient. If patient agrees and signed consent, check box
Completed
Submit
Should be Empty: