New Patient Forms

MEDICAL HISTORY FORM

PATIENT NAME:

Date

REFERRING PHYSICIAN’S NAME:

DATE OF INJURY/ONSET:

PRIMARY CARE PHYSICIAN’S NAME:

ARE YOU PRESENTLY WORKING?

YES NO

CAUSE OF INJURY OR ONSET:

DATE OF NEXT MD APPT:

WHAT IS YOUR REASON FOR ATTENDING THERAPY:

WHAT ARE YOUR PERSONAL GOALS/OUTCOMES YOU HOPE TO ACHIEVE FROM THERAPY?

HAVE YOU HAD PRIOR PHYSICAL/OCCUPATIONAL THERAPY FOR THIS CONDITION? (select one)

PHYSICAL OCCUPATIONAL

YES NO

WHAT WAS DONE?

WHAT WERE THE RESULTS?

ARE YOU ALLERGIC TO LATEX?

YES NO

If yes what is the Reaction

DO YOU CURRENTLY HAVE ANY “FLU TYPE” SYMPTOMS (I.E. FEVER, COUGHING)?

YES NO

IF YES, WHAT SYMPTOMS:

If checked any above, explain:

ANY OTHER MEDICAL PROBLEMS:

CURRENT MEDICATIONS:

ALLERGIES:

Add Medication

HAVE YOU HAD PRIOR PHYSICAL THERAPY THIS CALENDAR/INS YEAR?

YES NO

HOW MANY

HAVE YOU HAD PRIOR CHIROPRACTOR SERVICE THIS CALENDAR/INS YEAR.

YES NO

HOW MANY

WAS IT RECEIVED AT:

HOSPITAL OUTPATIENT CENTER HOME HEALTH

HOW MANY

PATIENT:

Date:

REVIEWED BY THERAPIST(S):

Date:

Cancellation No Show Policy

At Optimal Physical Therapy, our goal is to make our clinic accessible to as many patients as possible. Because our services are in high demand, we maintain a full schedule. This allows us to provide each patient with the individual attention necessary for the highest quality care.

When a patient cancels shortly before an appointment or is a “no-show,” we miss the opportunity to treat another patient. We appreciate your courtesy in calling us as soon as possible if you must cancel your scheduled appointment. Your time slot then has a better chance of being reassigned to another patient.

In the event you do not notify us within 24 hours of your appointment time to cancel your appointment you will be charged $50.00. This charge is not billed to your insurance company and you will be responsible for the Cancellation Fee.

Exceptions:
We understand those emergencies or other circumstances beyond your control that may require you to be late or miss an appointment. If so, please let us know as soon as possible. We may consider exceptions on a case-by-case basis. We appreciate your understanding and cooperation.

Discharge:
If you have 3 cancellations or no-shows and are non-compliant you may be discharged from our care. If you are feeling better and are not in need of Physical Therapy, please let us know so we can forward a note to your physician or surgeon.

CONSENT TO TREATMENT

I consent to rehabilitation and related services at: Optimal Physical Therapy and Wellness In doing so, I understand, acknowledge, and affirm that such rehabilitation and related services may involve bodily contact, touch and/or direct contact of a sensitive nature.

Initials:

TREATMENT OF MINORS

I, as a parent/guardian of (a minor) Name: (Please Input below) 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.

Initials:

LIABILITY

I know and agree that: Optimal Physical Therapy and Wellness is not responsible for loss or damage to personal valuables.

Initials:

WAIVER AND RELEASE

I hereby release, discharge, and acquit: Optimal Physical Therapy and Wellness, its agents, representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services.

Initials:

AUTHORIZATION OF PAYMENT

I hereby assign all benefits directly to: Optimal Physical Therapy and Wellness I also authorize release of any medical records to other healthcare providers as necessary to facilitate my treatment and to other third parties as necessary to process medical claims and otherwise permitted or required in the Notice of Privacy Practices.

Initials:

FINANCIAL POLICY

I understand fully that, in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment.

To assist in establishing your account, please:
- Supply all necessary information for accurate billing of your claim, including your insurance card, driver's license, employer information, and demographic information.
- Satisfy all insurance co-payments, co-insurance, deductibles, and non-covered services on the day services are rendered.
- Provide your insurance company and us with any additional information requested to complete the processing of claims filed on your behalf.

Initials:

NOTICE OF PRIVACY/PATIENT BILL OF RIGHTS

I acknowledge receipt of Notice of Privacy Practices.

Initials:

I acknowledge receipt of the Statement of Patient Rights.

Initials:

I certify that all of the information provided herein is true and correct.

Patient/Guardian Signature:

Date:

Witness Signature:

Date:

DISCLOSURE OF MEDICAL RECORDS:

I authorize the following individuals to have access to my medical and billing records:

Name

Relationship

Name

Relationship

Signature of Patient

Date:

Specify if other:

Your information will be encrypted.