MCKEE THERAPY SPECIALISTS
The Leader in Manual Based Personal Physical Therapy
18858 N Dale Mabry Hwy, Lutz, FL 33548
Phone- (813) 693-4000
Fax- (813) 693-4357
Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Zip:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email Address:
example@example.com
Insured Person's Name:
Employer:
Work related injury?
Y
N
Referred By:
Motor vehicle accident?
Y
N
Primary Insurance:
Secondary Insurance:
Chief complaint:
Date of Injury or Surgery:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did injury occur?
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By signing below,
1) I consent to treatment at McKee Therapy Specialists (or treatment of child if signing as parent/guardian).
2) I authorize McKee Therapy Specialists to release medical information to my insurance and my physician.
3) I authorize McKee Therapy Specialists to bill and collect payments from my insurance company.
4) I agree to accept financial responsibility for my treatment including co-pays and deductibles.
6) I agree to accept financial responsibility for all
cancelled visits without 24 hour notice
resulting in a charge of
$45.00
per missed visit.
7) I acknowledge receipt of the "Federal Notice of Information Policies"
8) I acknowledge the health and personal information above is true to the best of my knowledge.
Signature:
Printed Name:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MEDICARE PATIENTS ONLY:
Based on Medicare policy, Medicare will
NOT
allow outpatient services to be rendered at the same time as home health services. You
MUST
notify us immediately if at any point you receive Home Health services while you are being treated at McKee Therapy Specialists. If we are not notified, you will be liable for payments.
Signature:
Printed Name:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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MCKEE THERAPY SPECIALISTS
The Leader in Manual Based Personal Physical Therapy
NAME:
DATE OF NEXT MD APPOINTMENT:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical History
Describe briefly the history of your present ACCIDENT, INJURY, and ILLNESS OR CONDITION
Onset Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description:
Please list any special concerns, questions or expectations:
Have you fallen in the past year?
If so, how many times?
If so, did you sustain an injury?
Have you had any physical therapy during the current calendar year?
If yes,
Have you had physical therapy for the same condition for which you are here for today?
please indicate where and when:
List ALL medications you are currently taking:
Please list recent diagnostic studies (CAT scan, MRI, X-ray, Etc)
Do you have METAL anywhere in your body (other than teeth), such as pins/plates, pacemaker, stents, etc.? Describe:
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Please list ALL surgeries you have had: please give procedures and dates, if possible:
Have you ever had: (Please circle yes or no)
High blood pressure
Yes
No
Arthritis/Osteoarthritis
Yes
No
Heart Disorders
Yes
No
Osteoporosis
Yes
No
High Cholesterol
Yes
No
Cancer
Yes
No
Lung Disorders
Yes
No
Pacemaker
Yes
No
Circulation Disorders
Yes
No
Are you pregnant?
Yes
No
Dizzy Spells
Yes
No
Allergies to tapes or lotions?
Yes
No
Seizures
Yes
No
Recent Weight Loss
Yes
No
Diabetes
Yes
No
SIGNATURE:
DATE:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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