Queen City PT Online Intake Form

  • Your Online Intake

    Please fill out the online intake form to become a new patient! Once we receive your information, we will call you to schedule an appointment as soon as possible!
  • Date of Birth*
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  • Format: (000) 000-0000.

  • Please tell us about your condition

  • How did your injury occur/when did your symptoms begin?:*
  • Date of Your Car Accident*
     - -
  • Date of Your Work Accident*
     - -
  • What day did you injury occur/when did your symptoms begin?*
     - -
  • Did you visit the emergency room after the injury?*
  • Please select the date of visit:*
     - -
  • Were you admitted to the hospital following your emergency visit?*
  • Have you had any of the following diagnostic tests done related to this incident?*
  • Do you have a written referral/prescription from a physician for your injury/condition?*

  • That's okay! In New York State we are allowed to treat you for 10 visits or 30 days without a physician referral/prescription. If you would like to continue PT beyond that point, we can help you obtain one!

  • Do you have an attorney for this injury?*
  • Have you received or are you receiving any of the following services for this injury?*
  • Are you currently working?*
  • Do you work Full-Time or Part-Time?*
  • Why are you not working?*
  • When was your last day of work?*
     - -
  • Do you have a Primary Care Physician*
  • Do you have Primary Health Insurance?*

  • Medical History

    Please check the box if you currently have or have previously had any of the following medical conditions. You must select "None" if do not have or have not had any medical conditions.
  • Cardiovascular/Heart*
  • Skeletal System*
  • Pulmonary/Lungs*
  • GI/Pelvis/Endocrine*
  • Neuro/Brain*
  • Skin*
  • Psychological/Mental Health*
  • Other Areas*
  • Allergies*
  • Substance Use*
  • Are you pregnant or is pregnancy suspected at this time.*

  • Assistive Devices/Adaptive Equipment

    Please check the box if you currently use any of the following pieces of medical equipment. You must select "None" if do not use any medical equipment.
  • Do you use any of the following assistive devices?*
  • Do you currently use any of the following equipment?*

  • Surgical History

  • Have you had any prior surgeries or medical procedures?*

  • Please list all previous surgeries or medical procedures you have had in the section below. Click "Add Row" to add another surgery or medical procedure: 

  • Medications

  • Are you currently taking any medications.*

  • Please list all medications you are currently taking in the section below. Click "Add Row" to add another medication:

  • Pain Scale

    Please rate your pain on the following scale: 0 = No pain 1 = Mild 5 = Moderate 10 = Severe

  • Please Describe Your Symptoms Using The Checkboxes Below

    You must select "None" if do not have any of the following symptoms.
  • What does your pain feel like?*
  • How often do you have pain?*
  • What makes your pain worse?*
  • What makes your pain better?*
  • Have any of the following activities been negatively affected since your injury?*
  • Sine your injury, symptoms are:*

  • Current Functional Limitations

    Please check the boxes below if the activity has become PAINFUL, DIFFICULT, or ABNORMAL since the injury or condition began. You must select "None" if do not have any of the following limitations.
  • MOBILITY*
  • SELF CARE*
  • DOMESTIC LIFE*
  • INTERPERSONAL RELATIONSHIPS*

  • INFORMED CONSENT FOR EXAMINATION AND TREATMENT

    I hereby consent to the performance of examination and treatment on me by the licensed doctors of physical therapy that may be employed by or engaged in practice at Queen City Physical Therapy.

    I understand that neither physical therapy nor medical treatment is an exact science and that my care may involve judgements to attempt to anticipate or explain risks and complications and an undesirable result does not necessarily indicate an error in judgement. No guarantee for results can be made or expected but rather I wish to rely on the doctor to choose and recommend a best course of treatment based upon facts known that is in my best interest.

    I further understand that there is a certain degree of risk associated with physical therapy which rarely includes, but is not limited to fractures, disc injuries, strokes, and strain/ sprains and am therefore willing to accept and consent to the risk associated with the care I am about to receive.

    I have read the above information regarding consent. By signing below, I agree and intend this consent form to cover the procedures prescribed for my condition and for any future conditions for which I seek treatment at Queen City Physical Therapy.

  • PRIVATE HEALTH INFORMATION POLICY

    We may use and disclose your PHI (private health information) in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose your PHI in response to our discovery request, subpoena, or other lawful process by another party involved in the dispute. We may use or disclose your PHI for workers compensation and similar programs. We may use a sign-in sheet at the front desk, and we may call you in to see the doctor by name. 

    We may contact you by mail or phone, at your residence, to remind you of appointments or to provide information about treatment alternatives. Unless you instruct us otherwise, we may mail you a postcard reminding you to make an appointment, and we may leave a message for you on any answering device or with any person who answers the phone at your residence. You can make a responsible request for us to use alternative methods of communicating with you in a confidential manner. These requests must be submitted in writing in a clear and concise fashion. We are not required to agree with your request. However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when information is necessary to treat you.

    Rights that you have: You have the right to request restrictions on some of the uses or disclosures described above. Except as stated, we are not required to agree to such restrictions. You have the right to inspect and obtain copies of your medical information. You have the right to request amendments to your medical information. Such requests must be in writing and must state the reason for the requested amendment. We will notify you as to whether we agree or disagree with the requested amendment. If we disagree with any requested amendment, we will further notify you of your rights. You have the right to request an accounting of any disclosure we make of your medical information except for disclosures we make you, to carry out treatment, payment or healthcare operations, as requested by your written authorization, as permitted or required under 45 CFR 164.502, for emergency or notification purposes, for national security or intelligence purposes as permitted by law, or to correctional facilities or law enforcement officials as permitted by law. You have the right to receive a paper copy of this notice. To obtain a paper copy of this notice, please contact our office.

    You have the right to file a complaint if you believe your privacy rights have been violated. You may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing and addressed to this office at the above address. You will not be penalized for filing a complaint. This privacy policy is subject to change as circumstances dictate. Any changes will be effective upon the release of a revised policy as stated in this notice.

  • OFFICE POLICIES

    Appointment Policy:

    Every patient is equally important to us here at Queen City Physical Therapy, and we want to treat you with exceptional care and devotion. In order to provide this quality of service, we ask that you please arrive 10 - 15 minutes before your scheduled appointment time. This allows for optimal treatment time and enables each patient to receive the quality care he or she deserves.

     

    Cancellation/No-Show/Non-Compliance Policy:

    A 24-hour notice is required for cancellation of an appointment except in the event of emergency situations. Failure to cancel three or more appointments without 24-hour notice and/or if the patient does not show up for three or more appointments, the patient may be administratively discharged. Our office also reserves the right to administratively discharge you from care due to improper or offensive behavior at our office. Physical therapy requires effort and commitment in order to achieve results. Please remain compliant with your treatment program in order to gain maximal benefit, and call ahead to reschedule your appointment.

     

    Payment/Copay Policy: Your insurance coverage may not fully cover all treatment that is recommended. Co-pays are due PRIOR to being treated. If your co-pay is not paid at the time of your visit and/or your account has a co-pay balance you will be required to pay your balance in full prior to being treated. Should you maintain a balance, you will be required to reschedule your office visit.

     

    Data Storage Policy: Queen City Physical Therapy, PLLC commits to respecting the privacy of all its patients and to protecting any data about patients from outside parties. To this end management is committed to maintaining a secure environment in which to process cardholder information so that we can meet these promises. We follow the Payment Card Industry Data Security Standard (PCI DSS) when handling credit/debit card data. We collect your payment details, and other information to process your copays at the start of your treatment session. We process the billing information ourselves (e.g., date of payment, credit/debit card owner's full name, credit/debit card number, its security code and expiration date). WE DO NOT STORE any of our patient's credit/debit card information. I authorize Queen City Physical Therapy, PLLC to charge my card for payment of at the start of each treatment session. 

  • You've Completed Your Intake!

    Please sign below and click "Submit" to become a new patient
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