Please help us serve you better by taking a few minutes to provide the following information
The following is very important in our evaluation process. Please fill out these forms as specifically as possible
Please rate your pain in the last 24-72 hours
Using the "0-10" scale where 0 is no pain and 10 is the worst possible pain.
List ALL medications which you are currently taking, the condition for which you are using them, the dose, and their effectiveness. (Include supplements, herbal and homeopathic remedies
If sleep is a problem, answer these questions:
List all the Tasks/Activities that you have difficult performing and your tolerance (minutes/hours).
If you are no longer able to perfom an activity, your tolerance would be "0".
Please list the activities that you would like to be able to do as a result of therapy.
I do hereby agree and give my consent for Physical Therapy San Pedro to furnish care and treatment that is considered necessary and proper in diagnosing or treating my physical condition.
I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.
I hereby certify that all the above information is true to the best of my knowledge.
I understand that Physical Therapy San Pedro will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.
Photographs taken during the duration of treatment will be used for postural comparison purposes and as educational tools. By signing below, I consent to the use of these photographs in a professional manner.
In addition, photographs and video will be used as educational tools for website and social media purposes. By signing below, I consent to the use of these photographs in this manner.
At the time you book your initial appointment you will be required to put a credit card on file.
All cancellations need to be made 24 hours prior to your scheduled appointment.
If you do not show up for your appointment or cancel within 24 hours, your card on file will be charged for 100% of the session price.
You will be notified prior to the charge being applied.
To avoid this cancellation fee, you will also be offered a Telehealth appointment.
Your initial evaluation is $195 and follow up treatment sessions are $155. Payment, in the form of cash, check or credit card, is due at the time of each visit.
We are not billing your insurance company. However, the payments you make may be reimbursable by your insurance company under your out of network physical therapy benefits; the exact percentage depends upon your plan. Due to the complex nature of insurance claims and reimbursement, we make no promises as to whether you will receive reimbursement.
We will assist you in every way possible. Payment is due at the time of service.
I have read and understand the above policies:
Thank you for your cooperation and business.
CONSENT FOR TELEHEALTH SERVICES (Initial Below)
I, THE PATIENT OR RESPONSIBLE PARTY OF THE PATIENT, HAVE READ, UNDERSTAND, AND AGREE TO THE STATEMENTS CONTAINED HEREIN: (Initial Below)