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 difficulty performing and your tolerance (minutes/hours).
If you are no longer able to perform an activity, your tolerance would be "0".
Please list the activites 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.
To Whom It May Concern:
I__________________________________________,allow assignment of benefits to be issued to the treating provider,
Dr. Janae Brown, PT, DPT.
I am aware that Physical Therapy San Pedro is a non- participating provider.
If you receive payment made directly to you, please cash these payments and make a payment directly to:
Dr. Ja’nae Brown, PT, DPT
481 W 6th Street San Pedro, CA 90731
*Note: payments can also be made via website phsyicaltherapysanpedro.com
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, you will be responsible to pay for 100% of the session.
To avoid this cancellation fee, your appointment will be automatically adjusted from an in-person to Telehealth.
Your insurance benefits will be checked and verified prior to your initial treatment and you will be notified of your out of pocket expense. Treatment will be billed under your out of network physical therapy benefits and payment for the difference in coverage based on copayment and coinsurance responsibilities, in the form of cash, check or credit card, is due at the time of each visit. Because Dr. Ja’nae Brown is an out of network provider, your insurance may send payments directly to you, the patient. Please contact our office upon receipt of payment. You will be billed the full amount charged to your insurance company until payment is remitted to Dr. Ja’nae Brown.
I have read, understood and agree to 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)