Clone of Injury Screen Registration Form

Online Physical Therapy Application

Please complete to register.
What to Expect:

If you're interested in a virtual physical therapy evaluation, we invite you to apply. The initial evaluation will be conducted via Zoom and includes a detailed discussion of your pain or injury, including its history and mechanism. This will be followed by movement assessments to establish a physical therapy diagnosis and create a personalized treatment plan.

The initial evaluation is a one-time investment of $150. However, if you choose to move forward with the treatment plan, this amount will be applied toward your ongoing care.

Your individualized treatment program may include:
- Weekly or bi-weekly check-ins
- A customized exercise plan to support your recovery
- Direct communication with your physical therapist through the PTEverywhere app
- The option to schedule additional virtual appointments as needed
Once your application is submitted, a physical therapist will contact you to schedule your evaluation.
Personal Information
Full Name*

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

MonthDayYear
Date
Gender

MaleFemale
Medical Information
Please explain your current pain/injury:*
When did your symptoms begin (yesterday, 2 weeks, on/off 10 years, etc.)?*
Describe any activities or movements that AGGRAVATE your symptoms?*
Describe any activities, movements, or self-care that REDUCES your symptoms?*
What other types of treatment have you had for the symptoms (physical therapy, chiropractor, massage, medication, imaging, etc.)? *
Do you have any medical conditions or allergies? (cancer, autoimmune disease, strokes, etc.)*

YesNo
If yes, please provide details
What is your availability to schedule an evaluation? (best day/time)*
What time zone are you located in?*
Do you prefer to be reached by text message, email, phone call, or instagram?*
Instagram Handle
CONSENT

Please read and sign.
Before proceeding with the virtual initital evaluation and treatment, I, the undersigned, consent to the evaluation and assessment of my injury by the healthcare professional. I understand that the evaluation process will involve questions regarding my medical history, the mechanism of the injury, and an examination of the affected area, which may movement assessments. I acknowledge that the healthcare professional may recommend treatment interventions, which could include but are not limited to, rest, ice, compression, elevation (R.I.C.E.), therapeutic exercises, or other modalities as deemed appropriate for my condition. I am aware that all treatments will be explained to me, and I will have the opportunity to ask questions before any interventions are performed. I understand that my participation in the evaluation and treatment is voluntary, and I may withdraw my consent at any time.
Signature*

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HIPAA Authorization/Privacy & Release of Information:

Please Read and sign.
I understand that Eternity Physical Therapy & Wellness, PC will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. Health information about you is personal, and we are committed to protecting it. We create a record of the care, services, and assessments you receive at Eternity Physical Therapy & Wellness, PC. We need this record to provide you quality care and to comply with certain legal requirements. This notice applies to all of the health-related records of your care generated by Eternity Physical Therapy & Wellness, PC and may need to be shared with your personal practitioner. Eternity Physical Therapy & Wellness, PC is required by law to make sure that health information that identifies you is kept private. We are required to give you this notice of our legal duties and privacy practices with respect to health information about you, and not retaliate against you for filing a complaint. I understand Eternity Physical Therapy & Wellness PC's HIPAA and Privacy Practices.

Release of Information: Eternity Physical Therapy & Wellness, PC releases patient health care information for purposes of treatment or payment, or to other health care organizations, as explained in our HIPAA Notice of Privacy Practice. I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits.
Signature*

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Online Physical Therapy Application

Personal Information

Medical Information

CONSENT

HIPAA Authorization/Privacy & Release of Information: