Intake Form
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Payson Physical Therapy
405 W Main St, Suite D, Payson, 85541
www.paysonphysicaltherapy.com
Name: ________________________________ Date of Birth: _____\_____\_________
Address: _________________________________ Soc Sec #: _____________________
City: _____________________________________ State: _____ Zip: ________________
Home Phone: __________________ Work Phone: ________________
Cell Phone: _____________________
Insured Person’s Name: ______________________________________
Date of Birth: _____\_____\_________
Employer: _____________________________________ Work related injury? Y N
Referred By: ________________________________ Motor vehicle accident? Y N
Primary Insurance: _________________________________________________________
Secondary Insurance:________________________________________________________
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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: _______________________________________________________
Printed Name: ___________________________________________________
Date: _____\_____\_________
Please let us know if you have any questions or concerns regarding treatment, scheduling, or billing.