Jarvis Pediatric Therapy Inc.

New Patient Form
Date*

MonthDayYear
Child’s First and Last Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Email*
Primary Language

EnglishSpanishOther
Interpreter Needed?

YesNo
Parent / Guardian
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Format: (000) 000-0000.
Cell
Format: (000) 000-0000.
Father’s Employer
Work Phone
Format: (000) 000-0000.
Mother’s Employer
Work Phone
Format: (000) 000-0000.
Primary Care Physician Name
Clinic Name
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insurance
Policy ID Number
Subscriber
Date of Birth

MonthDayYear
SSN
Policy Group Name/Number
Tefra/Medicaid Number
Please have insurance and/or Medicaid cards available at the time of the appointment.

* ALL AREAS MUST BE COMPLETED FOR BILLING PURPOSES. WE ARE UNABLE TO BILL INSURANCE/MEDICAID WITHOUT THIS INFORMATION.

IF THEY ARE NOT COMPLETED YOU WILL BE BILLED.
Emergency Contact Information

In case of an emergency where we are unable to contact you, this page will be given to emergency personnel. Please fill out all spaces and note any other comments we may need to know.

Who do we contact in case of emergency?
- Emergency Contact #1
- Emergency Contact #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to child
- Emergency Contact #2
- Emergency Contact #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to child
If we are not able to reach either contact person, do we have your permission for Jarvis Pediatric Therapy, Inc. to contact 911/emergency services?

YesNo
Medical History significant for emergency services. i.e. asthma, diabetes, etc
Drug/Food allergies
Pediatrician
Hospital of Choice
Please list any and all adults (other than yourself) that DO have permission to pick up your child from therapy
Please list anyone that does NOT have your permission to pick up your child from therapy

Authorizations, Acknowledgements, and Agreements
Child's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Legal Guardian (PRINT)*
1. Authorization for Evaluation and Treatment I authorize physical (including orthotics), speech, and/or occupational therapy evaluation(s) and treatment for the above said child as ordered by my child’s physician.
Date

MonthDayYear
2. Acknowledgement of Privacy Practices I acknowledge that I have received a copy of Jarvis Pediatric Therapy, Inc.’s Notice of Privacy Practices.
Date

MonthDayYear
3. Authorization for Release of Medical Information I, the legal parent/guardian of the above said child, do hereby give my permission to Jarvis Pediatric Therapy, Inc. to use my child’s medical records for any purpose deemed necessary.
Date

MonthDayYear
4. Consent for Child Observation and Intern/Student Interaction I, the legal parent/guardian of the above said child, understand that Jarvis Pediatric Therapy, Inc. is a teaching facility. I give permission for my child to be observed through supervised observations undertaken as part of an academic internship, practicum, and/or observation requirement for students. Interns may be used in a supportcapacity or as administrative assistants. They may participate in partner activities with my child while his/her therapist is in direct supervision. When reflecting on the observations, students will use codes to protect my child’s identity and right to confidentiality.
Date

MonthDayYear
5. Authorization to Photograph/Video for Promotional Use I, the legal parent/guardian of the above said child, give Jarvis Pediatric Therapy, Inc. the right and privilege to photograph/video my child for the use of developing and publicly releasing promotional information. I understand that my child’s image may be viewed in the form of magazines, brochures, posters, and Jarvis Pediatric Therapy website jarvistherapy.com No identifying information will be revealed.
Date

MonthDayYear
6. Authorization to Photograph/Video for Instructional Use I, the legal parent/guardian of the above said child, give Jarvis Pediatric Therapy, Inc. the right and privilege to photograph/video my child for educational and instructional purposes. I understand that videos, and/or photographs of my child may be viewed and discussed with other healthcare professionals or parents of the child.
Date

MonthDayYear
7. Social Media Waiver I, the legal parent/guardian of the above said child, hereby authorize Jarvis Pediatric Therapy, Inc. to publish on social media Facebook No identifying information will be shared.
Date

MonthDayYear
Wendy Jarvis, OTR/L
Luke Hill, OTR/L
Brenda Rodriguez
Amanda Myers, PT, DPT
2070 McKenzie St., Suite C Springdale, AR 72762 5507 Walsh Lane, Suite 102 Rogers, AR 7758 Phone: 479.750.7778 Fax: 479.750.7708 e-mail: jarvispediatric@sbcglobal.net
Payment Authorization and Financial Agreement

Please review the financial agreement for our practice. By signing this letter you are agreeing to all the terms in it. I authorize payment of medical benefits to be made directly to Jarvis Pediatric Therapy, Inc. for services rendered. I understand that while insurance may cover some of my expenses, I will be personally responsible for anything not handled by my insurance. I understand that it is my responsibility to understand the coverage and limitations of my insurance. I agree to either fully pay or set up a payment plan and begin payment for all charges within 30 days of the receipt of my child’s patient statement. Failure to pay outstanding balances will result in additional charges for collection and/or attorney’s fees.
Signature
Date

MonthDayYear
HIPAA AUTHORIZATION
Child’s Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Section I hearby authorize Jarvis Pediatric Therapy, Inc. to release or obtain my individually indentifyable information, including contact information, pictures of my child, information about physical health and/or mental health, physical or mental condition, healthcare or other services, and payment for services.

I understand that:

• I am entitled to a copy of this form A copy of the permission form is as valid as the original

• I may revoke this authorization at any time by notifying Jarvis Pediatric Therapy, Inc. in writing.

• This will not affect any action Jarvis Pediatric Therapy, Inc. took in reliance on this authorization before it was revoked.

• If I refuse to authorize disclosure of my child’s unrelated healthcare information, then Jarvis Pediatric Therapy, Inc. will not deny services.

• Once information is released to a third party, according to this authorization, Jarvis Pediatric Therapy, Inc. cannot prevent its re-disclosure.

• This authorization does not limit the ability of Jarvis Pediatric Therapy, Inc. to use or disclose my child’s health information as otherwise permitted by state and federal law.

• Disclosed health information may be oral or written.
Print Parent/Legal Guardian’s Name

First NameLast Name
Describe Relationship to Patient
Parent/Legal Guardian's Signature
Date

MonthDayYear
How did you find us?

My physician recommended youA friend/relative told meI found you on Facebook/InstagramI searched the webI know one of your employeesA current or former patient told me about youI saw your flyerI saw your team members at an eventOther
What is the patient's name?
Where have you seen the flyer?
What is the name of the team member?
Patient History
Patient's Name*

First NameLast Name
Date

MonthDayYear
Age
Primary Care Physician
Diagnosis
Primary Language Spoken at Home
Primary goals (what are your concerns)
Infant History
Complications/illness/infections/stress during pregnancy
Possible drug/alcohol use during pregnancy
When did mother discover she was pregnant?
Was mother on bed rest?
Gestational age (weeks)- premature/post-mature/full term
Complications during labor/delivery
Forceps/vacuum/c-section?
Birth Weight
Breast fed/How long?
Frequently spit up?
Problems with feeding?
Irritable/Happy/Quiet baby?
Sleeping problems as a baby?
Did baby arch head/back when upset?
Colic?
Reflux?
Did baby gain weight appropriately?
Other comments on infancy

New Patient Form

Please have insurance and/or Medicaid cards available at the time of the appointment.

Emergency Contact Information

Authorizations, Acknowledgements, and Agreements

Payment Authorization and Financial Agreement

HIPAA AUTHORIZATION

Patient History

Infant History

Developmental History

Medical History

Social History

School/Daycare History

Self-Care

AUTHORIZATION FOR RELEASE OF INFORMATION

Please Complete This Form If You Anticipate A Speech-Language Evaluation

Sensory Processing and Motor Control Questionnaire

Vestibular (Movement and Balance)

Gross Motor Control-Proprioception (Muscle and Joint Awareness/Function)

Tactile Function

Auditory

Oculo-Motor Control & Visual Perception

Fine Motor Control

Taste and Smell

Suck, Swallow, Breathe Synchrony

Self-Care

Motor Planning and Bilateral Motor Coordination

Emotions/Social Behaviors