Intown Physical Therapy Info and History

How did you find Intown PT?
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Mobile Phone #
E mail Address
example@example.com
Pronouns
He/him, She/her, They/them
Address

Address (Street)

Street Address Line 2

CityState

Zip Code
Emergency Contact Name
Emergency Contact Phone #
Relationship to Patient
PAYMENT AND INSURANCE FILING
Payment is requested at the time of service. You are responsible for the entire bill when services are rendered. Payment can be made by cash, check, MasterCard, Visa or American Express. We may bill your insurance carrier solely as a courtesy to you. We may check your insurance or Medicare benefits by contacting the insurance company or Medicare. This is an estimate, not a guarantee of benefits. If your insurance carrier does not remit payment within 30 days, or remits partial payment, we will invoice you for the balance. In the event that your insurance company requests a refund of payments already made, you will be responsible for the amount refunded. If any payments are made directly to you, you recognize an obligation to remit promptly to Intown PT. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner I will be responsible for all costs of collecting moneys owed. Where legal cases are pending settlement, we require that the full charge be paid at the time of treatment.
CONSENT FOR TREATMENT AND AUTHORIZATION
I do hereby consent for treatment at Intown Physical Therapy. I authorize Intown PT to release medical and supporting documentation of same as compiled in my medical record during this treatment or subsequent treatments for purposes of benefit payment. I further authorize my insurance benefits to be paid directly to Intown Physical Therapy, LLC when indicated on claim. I understand I am financially responsible for the services I received.
Signed:

Clear
Date:

MonthDayYear
Date
Relationship to Patient (self/parent/guardian):
CANCELLATION POLICY
Your appointment time is important to you, your physical therapist, and our other clients. The following policy is in place to ensure everyone receives timely, one-on-one, uninterrupted care.
- Please cancel your appointment if you have or have had vomiting, diarrhea or fever within the past 24 hours.
- For cancellations please call us at least 24 hours prior to your appointment time, or as soon as possible if you are ill. You may cancel via voicemail if the office is closed or there is no answer.
- There is a $55.00 fee charged if you do not attend your appointment and do not call to cancel at least 24 hours prior to your appointment time.
- If you are late for your appointment, we may ask you to reschedule at the therapist’s discretion.
By signing below you acknowledge that you have read and understood this cancellation policy and agree to comply with it as written.
COMMUNICATION RELEASE
I hereby give permission to the Intown PT office staff to notify me for appointment changes by voicemail, email or text message.

I agreeOther
Automated appointment reminders (check preferred)

Phone callText messageEmail
2. The individual(s) listed below is/are authorized to receive the above information on my behalf:
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY POLICY
By signing below I confirm that I have received and reviewed a copy of the Notice of Privacy Practices from Intown Physical Therapy and understand the information as outlined.

By signing below I agree to the above statements and verify that the above information is accurate to the best of my knowledge.
Signed:*

Clear
Relationship to Patient:
MEDICAL / SOCIAL HISTORY
Please check if you have ever had any of the following:

Alzheimer’s diseaseArthritisBlood disordersBroken bonesCancerChemical dependencyCirculation problemsDepressionDiabetes Type IDiabetes Type IIHead InjuryHeart ProblemsHepatitisKidney problemsHigh blood pressureLow blood sugarKidney problemsMultiple sclerosisOsteporosisOsteopeniaPacemakerPCOS/EndometriosisParkinson's DiseaseRepeated infectionsStrokeSeizuresSkin diseasesThyroid problemsTuberculosisUlcersOther
If yes, please provide details if desired:
Do you have any allergies?

LatexSeasonalOther topicalFoodMedicationOther
If yes, please provide details if desired
Please list all medications including dosages
You may upload a list of medications

Cancelof
Please indicate if you are currently taking any over-the-counter medications

AspirinTylenolAdvil/Motrin/IbuprofenAntacidLaxativesVitamins/Mineral SupplementsDecongestantsAntihistaminesOther
Have you recently had any of the following symptoms?

Bowel/bladder problemsLoss of appetiteChest painLoss of balanceCoordination problemsNausea/vomitingDifficulty swallowingPain at nightDizzy/LightheadednessShortness of breathFatigueUnexplained weaknessFever/chills/sweatsUnexplained weight changeOther
In the past month have you been feeling down, depressed or hopeless?

YesNo
Please list approximate dates for any hospitalizations or surgeries, as well as dates for childbirth. (a separate list may be provided)
Do you exercise regularly?

YesNo
If yes, what type of exercise?
If yes, on average, how many days per week and minutes per day?
With whom do you live? Check all that apply:

AloneSpouse or partner(s)Minor child(ren)Other familyOther
Occupation:
Work status (Check all that apply):

Full timePart timeRegular dutyLight dutyStudentUnemployedDisabilityRetiredOther
Do you currently use tobacco products?

YesNo
If yes, what type? How much per day?
Is there anything else you would like us to know about your general health and medical history?
Signed:

Clear
Should be Empty:

PAYMENT AND INSURANCE FILING

CONSENT FOR TREATMENT AND AUTHORIZATION

CANCELLATION POLICY

COMMUNICATION RELEASE

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY POLICY

MEDICAL / SOCIAL HISTORY