Patient Intake Form - Physical Therapy Evolution

Please note, this form is secure but it is not HIPAA-compliant. If you would rather print and bring this form with you to the appointment, click here.

Full Name *

Date of Birth *

Today's Date *

Address *

Address

City

State/Province

Zip/Postal

Phone (mobile) *

Phone (home)

Sex *

Male

Female

Email: (reminders will be sent to this address 24 hours prior to your appointment time) *

Primary Care Physician

Other Physician/Specialist

Were you Referred? *

Yes

No

By whom?

Is your condition due to an auto or work-related accident? *

Yes

No

Date of Accident

Did you file a claim?

Yes

No

Claim Number

Adjuster’s Name and Contact Number

Attorney Name and Contact Number

Treatment Consent

A licensed Physical Therapist will perform your evaluation and treatments. A variety of treatment techniques may be performed, as allowed under the physical therapist’s scope of practice. I hereby consent to Physical Therapy Evolution providing care and treatment for my condition.

Newsletter Consent

I agree to be notified via newsletter (an average of one to two times/year) for updates on location, pricing, offerings, etc. You may unsubscribe from the newsletter at any time should you choose not to receive these updates.

HIPAA Privacy Rule Acknowledgement

I acknowledge that I have read the HIPAA Privacy Notice, accessed online at www.hhs.gov/sites/default/files/privacysummary.pdf. I understand that I may receive a copy of this notice upon request at any time, and that I may inquire at Physical Therapy Evolution with any questions I may have regarding the Notice of Privacy Practices.

Cancellation and No-Show Policy

If I am unable to keep my appointment, I understand that a 24-hour notice is required (if my appointment is on a Monday, I understand cancellation notice is required on or before the preceding Friday), or I will incur a full appointment charge. We appreciate your understanding of this policy.

Checkboxes *

I understand this form is secure but it is not HIPAA compliant.

Responsible Party Signature *

Clear

Date *