Telehealth-Consent-Form

We are excited to offer Telehealth Physical Therapy to patients who have successfully completed their Home Health therapy programs.
Please complete and submit the below form. Your dedicated TherapyNow program administrator, Nancy Harvey, will reach out to you directly to complete the registration process and establish a date and time for your first telehealth visit.
Patient Name*

PrefixFirst NameLast Name
Patient Birth Date*

MonthDayYear
Date
Patient's Phone Number*
Please enter a valid phone number.
Type of Phone Number*
Patient's Email Address*
example@example.com
Insurance Company Name*
Enter the full name of your health insurance company
Insurance Policy Number*
Insurance Policy #
Physician's Name*

PrefixFirst NameLast Name
Physician's Phone*
Enter your physician's phone number, including area code
Health Questionnaire
Have you had surgery in the past 6-months from which you are still having trouble?*

YesNo
Where was the surgery?*
When was your most recent fall?*

Within the last 3 monthsMore than 3 months ago
How did the fall happen?*
What are you having the most trouble with right now?*
Please describe the particular challenges you are having right now, physically or with your health.
How has Home Health helped you?*
What major health conditions are you taking medicine for right now?*
Did you stop Home Health to go to the hospital at any time during your care?*

YesNo
Why did you have to stop Home Health to go to the hospital?*
What do you want us to help you with the most?*
Please indicate your personal goals for the next phase in your wellness program.
Please review the Patient Consent, Privacy Policy & Medicare Responsibility Forms. (Click down arrow button to download the forms. Click the print icon to print the forms.)
I was offered and/or accepted a copy of the Patient Consent, Privacy Policy, and Medicare Financial Responsibility forms from Venture Physical Therapy of Marietta.

Patient's Name: {patientName}
Guarantor (Signature)*

Clear
NOTE: You are the guarantor if you are age 19 and above.
Date & Time of Signature
Should be Empty:

We are excited to offer Telehealth Physical Therapy to patients who have successfully completed their Home Health therapy programs.

Health Questionnaire