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2019-06-20T14:27:33-04:00
Patient Registration
Patient Information
Patient Name
First
Last
Birthdate
MM slash DD slash YYYY
Sex
Male
Female
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Physical Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Cell Phone
Home Phone
May we leave messages?
Yes
No
Appointment Reminders
Text Message
Voicemail
Either
Employment Status
Full time
Part time
Student
Retired
Not Employed
Employer
Employer Phone
May we leave messages?
No
Yes
If minor, Guarantor
Guarantor Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Guarantor Phone
Emergency Contact
Relationship
Emergency Contact Phone
Your Email
Insurance
PLEASE PROVIDE US WITH YOUR INSURANCE CARD(S) AT YOUR FIRST APPOINTMENT.
WE REQUIRE THAT ALL CO-PAYS BE PAID AT EACH VISIT.
IF THE PATIENT IS A MINOR, THE GUARDIAN WHO IS THE GUARANTOR MUST SIGN THIS FORM.
PLEASE CALL YOUR INSURANCE COMPANY IF YOU DO NOT UNDERSTAND YOUR PHYSICAL THERAPY BENEFITS.
Do you have primary insurance?
Yes
No
Secondary Insurance?
No
Yes
Relationship to insured?
Self
Spouse
Dependent
IS THIS A WORKERS COMPENSATION CASE?
No
Yes
If so, case worker name and phone
IS THIS A MOTOR VEHICLE ACCIDENT?
No
Yes
If so, case worker name and phone
Additional Information
Are you currently seeing anyone else for Physical, Occupational, or Speech Therapy?
No
Yes
Have you seen anyone else this calendar year for Physical, Occupational, or Speech Therapy?
No
Yes
Have you had any Home Health visits for Physical, Occupational, or Speech Therapy?
No
Yes
If yes, how many visits have you had?
I will notify Allied Physical Therapy of any changes on this form and on my Medical Intake Form.
YES
I attest that all the information I have given is truthful, to the best of my knowledge, and that I have read, understand and agree to the policies at Allied Physical Therapy.
YES
Patient Signature (if minor, Gaurantor)
Date
MM slash DD slash YYYY
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