New Patient Paperwork Intake

Tristar Physical Therapy New Patient Intake Form
Personal Information
Name*

First NameLast Name
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Mobile Phone Number*
E-mail*
example@example.com
Social Security Number*
Occupation
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name
Emergency Contact
Name*

First NameLast Name
Phone Number*
Relation*
Referring Physician

First NameLast Name
Primary Care Physician Name

First NameLast Name
What Tristar Physical Therapy Location Are You Receiving Therapy At?*
Insurance Information
Name of Insurance Company
Policy #
Insured's Name (if different than yourself)

First NameLast Name
Date of Birth

MonthDayYear
Date
Insured’s Employer Name:
Insured's relationship to patient
Current Symptoms
Reason for your visit
Rate your chief complaint in order of severity from worst (5) to least (1)
Indicate the nature of your pain and symptoms

SharpDullPiercingShootingAchingTinglingNumbnessStabbingOther
What makes your condition worse?
What makes your condition better?
How often do you experience the pain/symptoms?
Are your symptoms related to a work injury?

YesNo
Or a motor vehicle accident?

YesNo
List past surgeries or major medical problems/illness
List of Medication
Since your symptoms began, have you noticed any of the following

FatiguePain at nightLeg swellingWeight loss/gainNumbness or tinglingAbdominal painFaintingSkin changesHeart palpitationsOther
Medical History

	Yes	No
High Blood Pressure
Neck or Back Problems
Are you pregnant
Do you have osteoporosis

Are you currently under a care of any healthcare provider other than who prescribed your Physical Therapist*

YesNo
If yes, what is the reason?
Other Comments

Authorization/Consent
As a patient of Tristar Physical Therapy, I understand that my care is the responsibility of Tristar Physical Therapy's practitioners.
- Cooperation with Treatment: I agree to attend scheduled appointments and follow the home therapy program. I will discuss any issues with my therapist.
- No Warranty: I understand there are no guarantees for a cure or improvement. My therapist will explain the treatment goals and options before I consent.
- Informed Consent: I have been informed about the potential risks, benefits, and alternatives of therapy treatment. Information about available treatments will be provided at the initial visit.
- Potential Risks: Treatment may temporarily increase pain or discomfort. If it persists, I will contact my therapist.
- Potential Benefits: Treatment may improve symptoms, daily activities, strength, flexibility, endurance, and pain management.
- Alternatives: I can discuss medical, surgical, or pharmacological alternatives with my therapist and physician.
- Payment: I am responsible for charges not covered by insurance.
Message frequency will be 2 times per month and will include SMS messages, appointment scheduling and reminders, etc. and will vary based on your appointments and needs. Consent is not a condition of purchase. Message and data rates may apply. Reply 'STOP' to unsubscribe at anytime. Reply 'HELP' for help. We do not share your mobile opt-in information with anyone. See our Privacy Policy and our messaging Terms and Conditions below for more information about how we handle your data.*

Yes - I understand and consent that I want to receive text messages from Tristar Physical Therapy using my phone number listed above.No - I DO NOT consent to this and do not want to receive text messages from Tristar Physical Therapy
Privacy Policy and Terms & Conditions

Privacy Policy
View Privacy Policy

Terms and Conditions
View Terms

Direct Access Attestation and Medical Release

(Licensed health practitioners include a Doctor of Medicine, osteopathy, chiropractic, podiatry, dental surgery, licensed nurse practitioner, or licensed physician assistant)
I AM NOT under the care of a licensed health practitioner for the symptoms listed on this form and wish to seek physical therapy care at this time.I AM under the care of a licensed health practitioner for the symptoms listed on this form and wish to seek physical therapy care at this time.
Acknowledgment and Consent

I consent to the release of my initial evaluation and patient history to the practitioner within 14 days. I authorize the release of my health and treatment records to the practitioner.

Insurance and Payment Responsibility:
- Tristar Physical Therapy will send claims to my insurance, but I am responsible for understanding my benefits.
- I will pay all deductibles, copayments, and coinsurances.
- If insurance denies claims, I am responsible for payment.
- Prompt payment is required, and I may be billed if insurance fails to pay within 60 days.
- Accounts over 90 days past due may be sent to collections, and I will cover additional fees incurred.
Use of Personal Information:
- My personal information may be used or disclosed for treatment, claims processing, payment, service evaluation, and administrative operations.
- I can request restrictions on the use of my personal information, but Tristar Physical Therapy may not agree to all requests.
- I waive privacy concerns for information shared with my insurance carrier.
- I am financially responsible for non-covered services.
- I can revoke this consent at any time by written notice.
Appointment Attendance:
- Attendance of all scheduled appointments is essential for optimal results.
- A 24-hour notice is required for cancellations.
- After three cancellations or no-shows, I may be discharged from care, and my physician will be notified.
Insurance Assignment:
- I assign all insurance benefits to Tristar Physical Therapy.
- I am financially responsible for all charges.
- I authorize the use of my signature on insurance submissions.
- Tristar Physical Therapy may use and disclose my health information to my insurance for payment purposes.
Payment Plans:
- Declined payments incur a $25-$50 fee.
- I must update Tristar Physical Therapy with any changes to my card or address.
- Contact the billing department at 423-375-8907 for payment arrangements.
Tristar Physical Therapy Patient Policy

At Tristar Physical Therapy, our mission is to help you achieve full recovery. During your evaluation appointment, your physical therapist or occupational therapist will provide a personalized care plan and the required number of visits to reach your goals. Consistent attendance is vital; patients who attend all visits have a 93% higher chance of full recovery. Missing even one visit can significantly impact your progress. We can provide a study supporting this, but our primary goal is to ensure you understand the importance of attending every appointment.

Please read and sign below to indicate your understanding of our policy:
- Commitment to Recovery: Your full recovery depends on attending all scheduled appointments. After your evaluation, we will assist in scheduling these.
- Timeliness: Please arrive at least 5 minutes before your appointment, prepared and dressed for your session. This allows our team to provide you with the best care promptly.
- Late Arrivals: Being late may reduce your treatment time as we have reserved subsequent appointments for other patients.
- Notify Us If Running Late: If you are running late, please call us immediately. If you are more than 5 minutes late, we may need to reschedule your session, and a missed visit fee may apply.
- Illness: Notify us as soon as possible if you are ill and cannot attend a scheduled appointment.
- 24-Hour Notice for Cancellations: To ensure we can assist other patients, please provide at least 24 hours' notice for any appointment changes or cancellations.
- Missed Visit Fee: A $50 fee applies for cancellations or changes made with less than 24 hours' notice, in accordance with payer policy.
- Contact Information: Use our 24/7 answering machine for messages regarding illness, appointment changes, or cancellations. You will receive text messages for appointment reminders and progress updates, but rescheduling must be done by calling the office.
- Multiple Cancellations/No-Shows: Patients with multiple same-day cancellations or no-shows will be removed from the active schedule. We will notify your physician accordingly.
- Worker’s Compensation: If you are a worker's compensation patient, we must notify your claims adjuster if you cancel or no-show for an appointment.
We are dedicated to helping you reach your physical therapy goals. Please provide the required notice to ensure all patients receive the necessary care.
Name & signature of patient/legally responsible person*

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Date Signed*

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Date

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Tristar Physical Therapy New Patient Intake Form

Personal Information

Emergency Contact

Insurance Information

Current Symptoms

Medical History

Authorization/Consent

Privacy Policy and Terms & Conditions

Direct Access Attestation and Medical Release