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Welcome to the Johnson & Hayes Physical Therapists New Patient Registration Form
Our secure online form allows you to register for therapy at your own pace prior to your first appointment.  After you start your form you will find an option to save it at the bottom of the screen.  We recommend that you save the form periodically.  In addition to saving the information you've put into the form thus far, you will also receive a link via email to come back and complete it later.  We are excited to work with you!
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    Patient Name: {legalName}

    Date of Birth: {dateOf341}

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    0 = No Pain;  10 = The Worst Pain Imaginable / Emergency Room Pain
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    Separate each with a comma.  You can also choose to bring your medication list with you to your visit.
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    Slide your mouse down to the bottom of the window for an option to download the document.
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    I was offered and/or accepted a copy of the privacy policy from Johnson & Hayes Physical Therapists (see previous page)`.

    Patient's Name: {legalName}

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    NOTE:  You are the guarantor if you are age 19 and above.
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    Patient Name: {legalName}

    Patient Date of Birth: {dateOf341}

    Patient Address: {address4}

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    Please consider family or friends with whom you want to share your medical information.
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    When my information is used or disclosed as described in this authorization, I understand that it may be subject to disclosure by the persons listed above and may no longer be protected by the federal HIPPA Privacy Rule.

    I have the right to revoke this authorization in writing except to the extent that Johnson & Hayes has already acted in accordance with this authorization. My written revocation must be submitted to Johnson & Hayes Privacy Official at 4240 Balmoral Drive, Suite 100, Huntsville, AL 35801.

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