Intake Form

First name

Last name

Email

Phone

Refered By:

Occupation:

Emergency Contact

Please indicate your pain on a scale of 0-10 with 0 being no pain and 10 being the worst pain imaginable:

What makes your symptoms WORSE?

What makes your symptoms BETTER?

Have you sought previous treatment for this injury? If so, please describe.

Please list any Tests/Findings/X-Rays/MRIs/CT scans

Do you take your blood pressure regularly? If yes, what was your last reading?

What goals would you like to achieve in physical therapy?

MEDICATIONS Please list all prescription, over the counter, and herbal medications and supplements. Please list name, dosage, frequency, and route if possible.

Consent to Treatment (required). I consent to rehabilitation and related services at SANA Physical Therapy, PLLC. In so doing, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching, and or direct contact of sensitive nature.

Authorization of Payment: I hereby authorize my insurance carrier(s) to pay SANA Physical Therapy, PLLC directly for the services rendered. I also authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices.

Authorization of Payment: I understand fully that in the event my nsurance company or financially responsible party does not pay for the services I received, I will be financially responsible for payment up the discounted self-pay rate of service ($150 per evaluation, $125 per follow up treatments).

Cancellation Policy: I understand that a cancellation much be make at least 24 hours in advance of my scheduled appointment to avoid being charged a $75 cancellation fee.

Email Patient Reminders and Electronic Health Information: I undersand the risks of unencrypted email and do hereby give permission to SANA Physical Therapy, PLLC to send me personal health information via unencrypted email and/or patient appointment reminders.

Treatment of a Minor: I, as a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.

Signature

Patient Intake Form