PT Transfer Intake Form

PT Transfer Intake Form

Existing Federal Injury Group Patients who need to transfer to a new clinic location for Physical Therapy purposes.
If you need to pause filling out this form and return at any time, you will NOT be able to continue digitally due to HIPAA Compliance Regulations but you may PRINT this form with your current progress and the remaining fields you need to complete.

Please select 'Print Current Progress' to print out the form with the fields you've already completed filled out and the remaining required forms incomplete.

We greatly apologize for any inconvenience but thank you for understanding!
Today's Date:*

MonthDayYear
Date
Patient's Name:*

First NameLast Name
Patient's Email Address:*
example@example.com
Patient's Phone Number:*
Please enter a valid phone number.
Date of Birth: *

MonthDayYear
Date
Case Number:*
Social Security Number:*
Date of Original Intake: (When did you become a patient of a Federal Injury Group clinic?)*

MonthDayYear
Date
Original Clinic Location: (Which location did you complete your intake forms? Where have you been going for PT?)*

Federal Injury Treatment Centers of Florida (Dunedin)Federal Injury Treatment Centers of USA (Ocala)Federal Injury Doctors (St. Petersburg)DOL Doctors of Wesley ChapelFederal Injury Treatment Centers of the Palm Beaches (Delray Beach)Federal Injury Treatment Centers of North Palm BeachDr. Michael P. Newman (Miami - Kendall)
New Clinic Location: (Which location are you going to for PT?)*

Federal Injury Treatment Centers of Florida (Dunedin)Federal Injury Treatment Centers of USA (Ocala)Federal Injury Doctors (St. Petersburg)DOL Doctors of Wesley ChapelFederal Injury Treatment Centers of the Palm Beaches (Delray Beach)Federal Injury Treatment Centers of North Palm BeachDr. Michael P. Newman (Miami - Kendall)
Scheduled date to be seen at new PT Transfer Clinic: *

MonthDayYear
Date
Date of Original Injury:*

MonthDayYear
Date
Describe your current injury(s):*
How would you rate your current pain?*

1

2

3

4

5

6

7

8

9

10

1 is Less Pain, 10 is More Pain
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*
Please enter a valid phone number.
Emergency Contact Relation to Patient:*
Patient Signature*

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