PT Transfer Intake Form
Existing Federal Injury Group Patients who need to transfer to a new clinic location for Physical Therapy purposes.
Today's Date:
*
-
Month
-
Day
Year
Date
Patient's Name:
*
First Name
Last Name
Patient's Email Address:
*
example@example.com
Patient's Phone Number:
*
Please enter a valid phone number.
Date of Birth:
*
-
Month
-
Day
Year
Date
Case Number:
*
Social Security Number:
*
Date of Original Intake: (When did you become a patient of a Federal Injury Group clinic?)
*
-
Month
-
Day
Year
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 Chapel
Federal Injury Treatment Centers of the Palm Beaches (Delray Beach)
Federal Injury Treatment Centers of North Palm Beach
Dr. 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 Chapel
Federal Injury Treatment Centers of the Palm Beaches (Delray Beach)
Federal Injury Treatment Centers of North Palm Beach
Dr. Michael P. Newman (Miami - Kendall)
Scheduled date to be seen at new PT Transfer Clinic:
*
-
Month
-
Day
Year
Date
Date of Original Injury:
*
-
Month
-
Day
Year
Date
Describe your current injury(s):
*
How would you rate your current pain?
*
Less Pain
1
2
3
4
5
6
7
8
9
More Pain
10
1 is Less Pain, 10 is More Pain
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Emergency Contact Relation to Patient:
*
Patient Signature
*
Continue
Continue
Should be Empty: