UPDATED MEDICAL HISTORY & INSURANCE FORM

UPDATED MEDICAL HISTORY

Required if you or your child has not been seen at MPTC in more than 6 months.

First Name

Last Name

Street Address / Apt #

City and State

Zip Code

Date of Birth

Chronological Age

Parent or Guardian Name

Email address

Phone Number

Physician Name and Clinic

Medical Update

*procedures, testing, hospitalizations, new diagnoses, surgeries, etc.

Current Medication List

Updated Precaution or Allergies

*for example seizure disorder, nut allergy, epi pen, keep kosher

Dentist Name and Clinic

Orthodontist Name and Clinic

Dental Updates

*new night appliance, braces, palatal expander changes, etc.

INSURANCE INFORMATION

Primary Insurance Company

Effective Date

Member ID

Group Number

Subscriber Name and relationship to Client

Secondary Insurance Company

Effective Date

Member ID

Group Number

Subscriber Name and relationship to Client

SCHOOL INFORMATION

Name of School and grade

Name of Teacher(s)

Name of Therapist(s)

Speech, OT, PT, ABA, PSYCH, AUDIOLOGY, VISION

Email address of school contact

Phone Number to contact at School

*or main office

Are you interested in collaboration between the school and MPTC?

*If yes, you will need to fill out a Medical ROI at the office.

Concerns you are currently having regarding yourself or your child

What are you hoping to get out of the evaluation and treatment, if recommended.

Parent Signature

Date

Insurance Card Front and Back

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Evaluations or Reports from outside providers

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Drivers License

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