Payson Physical Therapy                                    

903 E Highway 260, Suite 1, Payson, 85541 

www.paysonphysicaltherapy.com                

 

Name: _____________________________________________________ Date of Birth: ___________________        

Address: ­­­­­­­­­­­___________________________________________________ Soc Sec #:  _____________________

City: ______________________________________________________ State: _____ Zip: ________________

Home Phone: __________________ Work Phone: _________________ Cell Phone: _____________________

Spouse/ Parent Name: _______________________________________________________________________ 

Employer: ___________________________________________________Work related injury?           Y    N                          

Referred By: _________________________________________________ Motor vehicle accident?     Y    N 

Primary Insurance: __________________________________________________________________________

Secondary Insurance: ________________________________________________________________________

 

Chief Complaint: ___________________________________________________________________________

 

Date of Injury or Surgery: ____________ How did injury occur? _____________________________________

 

History of:        Y   N   Diabetes (type___ years___)                Y   N   Heart Disease/ Arrhythmia

                        Y   N   Pacemaker                                           Y   N   Seizures

                        Y   N   Cancer (where___________)               Y   N   Decreased Sensation (where ____________)

 

Operations: ________________________________________________________________________________

 

Current medications: ________________________________________________________________________

 

Allergies: _________________________________________________________________________________

 

By signing below,

1)      I consent to treatment at Payson Physical Therapy (or treatment of child if signing as parent/ guardian).

2)      I authorize Payson Physical Therapy to release medical information to my insurance and my physician.

3)      I authorize Payson Physical Therapy to bill and collect payments from my insurance company.

4)      I agree to accept financial responsibility for my treatment including co-pays and deductibles.

5)      I acknowledge receipt of the “Federal Notice of Information Policies”

6)      I acknowledge the health and personal information above is true to the best of my knowledge.

 

 

Signature: _______________________________________________________ Date: ____________________

 

 

Please let us know if you have any questions or concerns regarding treatment, scheduling, or billing.