PATIENT INTAKE How was the Patient Referred? * FriendDoctorInternetIs a Previous PatientOthers PATIENT INFORMATION: First Name * Middle Initial (optional) Last Name * Patient email * Gender *MaleFemale DOB * Is Patient a Minor? *YesNo Best Phone (Cell/Home/Work)# * Other Phone (Cell/Home/Work)# (optional) Street * City * Zip * APPOINTMENT INFORMATION: Preferred Therapist Preferred DaysMonTueWedThuFriMorningAfternoonEveningOther Patient scheduling for *Physical TherapyAquatic Therapy (after evaluation) Wear Comfortable clothing + Walking Shoes. INSURANCE INFORMATION: (Bring Insurance Card + Photo ID) Even if this is related to an auto accident or work related injury, health insurance information is still required below. Primary * Phone # * PO Box ID#/Claim # * Group # * Subscriber*SelfRelation Subscriber First Name * Middle Initial * Last Name * Gender *MaleFemale DOB * Same Address? *YesNo Does the patient have *SecondarySupplementalN/A Secondary (optional) Phone # * PO Box * ID#/Claim # * Group # * Subscriber *SelfRelation Gender *MaleFemale DOB * Subscriber First Name * Middle Initial * Last Name * Have you had home health? *YesNo Home Health Name * Discharge Date * Was this due to a car accident? YesNo Insurer Claim # Date of Accident Claim Manager's Name Phone # Patient wasDriverPassengerPedestrianOther State the accident was in Was this due to a work related injury? YesNo Insurer Claim # Date of Injury Claim Manager's Name Phone # Employer State the injury was in Problem area(s) * Injury *AutoWorkSurgeryOther Surgery *YesNo Surgeon * Date of surgery * Do you have a prescription or referral from a provider? *YesNo Referring Practitioner/Clinic * Referral Date * *Once Intake form is Completed, Front desk will reach out for Scheduling
