Patient Intake Form

Patient Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
What is your gender?
Social Security # (000-00-0000)
Occupation
Employer
Parent's Name (if a minor):
Marital Status
Spouse's Name (if applicable)
# of Children:

Contact Information
Email Address
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone
Work Phone
Please enter a valid phone number.
Best way to reach you?

Home PhoneCell PhoneWork PhoneEmail
In Case of Emergency, Contact
Name
Relationship
Phone
Please enter a valid phone number.

Accident Information
Is your condition due to an accident?

NoYes
If YES, when was the accident?

MonthDayYear
Date
Type of accident:

AutoWorkHomeOther
To whom have you reported the accident?
Insurance:

Worker's CompEmployerOther
Attorney Name (if applicable):

Insurance
Who is responsible for this account?
Relationship to Patient
Insurance Company
Insurance ID #
Group/Claim #
Is patient covered by additional insurance?

YesNo
Insurance Company
Subscriber # and Name
Date of Birth

MonthDayYear
Date
Group #
Please present insurance card(s) so we can put a copy in your file.

INFORMED CONSENT
I have received information about my condition and proposed physical therapy treatment program as well as alternative courses of care, the benefits, the risks, and the side effects of the treatment and the consequences of not having the proposed treatment.

I understand that by receiving treatment by physical threapist without referral from a podiatrist, dentist, medical doctor or nurse practitioner; that my insurance company may not pay for services and that the treatment may be a covered expense if rendered pursuant to such referral.

My clinician has responded to all of my reports for information about the proposed treatment. I have read, or have had read to me the above consent. I have also had the opportunity to ask questions about this consent. By signing below, I consent to physical therapy treatment.
Date of First Treatment

MonthDayYear
Date
Patient's Name
Signature of Patient

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Date

MonthDayYear
Date
Parent/Guardian's Name
Signature of Parent/Guardian

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Date

MonthDayYear
Date
Should be Empty: