Registration Form
PATIENT REGISTRATION
Innovative Physical Therapy LLC
Name:
*
First
Last
Patient Information
Date of Birth:
Date of injury/onset:
Age:
Social Security:
Sex:
Male
Female
Marital Status:
Single
Married
Divorced
Widower
Address
Street Address
Address Line 2
City
State
Postal / Zip Code
Phone Number:
Email:
Employer Information
Employer:
Work Phone:
Injury Area:
Accident Related?
Yes
No
If yes:
Auto
Work
Referring Physician:
Phone:
Insurance Information
Primary Insurance:
Policyholder:
Policyholder's DOB:
Policyholder's SS#:
Group #:
Member ID #:
Emergency Contact:
Phone:
Additional Information
How did you hear about us:
Are you receiving or have you recently received home health services?
*
Yes
No
Are you receiving or have you received other therapy services?
*
Yes
No
Please initial after reading statements:
1. Consent to Treatment
I consent to rehabilitation and related services at Innovative Physical Therapy LLC. In so doing, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching, and/or direct contact of a sensitive nature.
2. Treatment of Minor:
I, as a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.
3. Liability
I know and agree that Innovative Physical Therapy LLC is not responsible for loss or damage to personal valuables.
4. Authorization of Payment
I hereby assign all benefits directly to Innovative Physical Therapy LLC and authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the services I received, I will be financially responsible for payment.
Initials:
I certify that the information I have reported above is correct and that as the Patient I have read, understand and fully accept the Conditions of Registration as stated above.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Patient Signature:
Date:
Your information will be encrypted.
