First Name*

Last Name*

Initial*

Street Address*

City*

State*

Zip*

Billing Address*

City*

State*

Zip*

Date of Birth*

Sex

Soc. Sec. # (optional)

Please complete the following as applicable:

Employer

Phone

Business Address

City

State

Zip

Occupation

Marital Status

Spouse Name

Employer

Phone

Date of Birth

Please complete if patient is a minor or dependent:

Mother's Name

Employer

Phone

Date of Birth

Father's Name

Employer

Phone

Date of Birth

Closest Relative or Friend (not living with you):

Phone

Address

City/ST

Do you have a follow-up appointment with the doctor who referred you to physical therapy?

Yes

Date

Referring Dr.

No, I am to call the doctor to schedule a follow up

No, doctor did not request to see me again

Insurance Information:

Is this a Motor Vehicle Accident claim?

Yes

If yes,

Date of injury

State

Is this a Workman’s Comp. claim?

Yes

If yes,

Date of injury

Claim # (if work. comp. or MVA):

Primary Ins:

ID #

Group #

Address

Phone

Secondary Ins:

ID #

Group #

Address

Phone

How did you hear about Summit Physical Therapy?

Physician

Advertising

Friend/Family

Why did you come to Summit Physical Therapy (what are your symptoms?)

Date of Onset

Date of Surgery (if applicable)

If you are having pain, please rate the intensity of your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible

Diabetes

Osteoarthritis

Osteoporosis

Pacemaker

Headaches

Cancer

Ringing in your ears

Rheumatic Arthritis

Hypoglycemia

High Blood Pressure

Heart Disease

Dizziness/Fainting

Surgeries

Bowel/Bladder Abnormality

Urine Leakage

None of the Above

If any of the items above have been selected, please briefly explain and give the date.

Numbness

Pins and Needles

Burning Pain

Stabbing Pain

Do you have any allergies?

Yes

If yes, please list

Have you had 2 or more falls or a fall resulting in injury in the past 12 months?

Yes

Are you presently taking any medication/supplements (prescription or over the counter)?

Yes

If yes, please list medications (Medication Name, Dosage/Frequency, Route (ie: oral, cream)):

Aerobics/Yoga

Bicycling

Cardio Machines

Cross Country Skiing

Dancing

Downhill Skiing

Gardening

Golf

Hiking

Running

Swimming

Tennis

Walking

Weight Training

Youth/HS sports

Other

What would you like to accomplish with therapy (what are your goals)?

Summit Physical Therapy is committed to providing quality physical therapy at reasonable cost. It is our policy to collect all accounts receivable within 90 days from date of service. For those patients with insurance coverage, we bill regularly. However, the patient is responsible to understand the specifics of their individual insurance coverage. The insurance contract is between the covered individual and the insurance company. The patient retains ultimate responsibility for financial charges incurred as a result of treatment. Our staff is available for assistance with insurance billing questions.

I hereby consent to such physical therapy procedures as may be rendered by Summit Physical Therapy. There is also consent for authorization of all insurance benefits to be paid directly to Summit Physical Therapy, and assumption of all financial responsibility for the balance of charges not included in the insurance coverage. A $25.00 fee will be charged for returned checks. Summit Physical Therapy has the authority to disclose medical information for treatment, payment and health operations. Summit Physical Therapy is released from disclosure of the patient’s records as provided by this paragraph.

I acknowledge that I have been informed and notified of the whereabouts of Summit Physical Therapy’s notice of information practices (how medical information regarding myself may be used and disclosed and how I can get access to this information).

Patient Information Form