Patient Intake – Green Physical Therapy and Wellness

Patient Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number

Sex *

Male
Female

Phone *

Email

Reason For Visit *

Referred By: *

Person to contact in case of Emergency

Relationship to Patient

Phone

Insurance, Cash Pay, or Work Comp? *

Insurance
Cash Pay
Work Comp

Primary Insurance

Insurance Company *

Policy Number *

Name of Subscriber *

First

Last

Subscriber Date of Birth *

Do you have a secondary insurance? *

Yes
No

Secondary Insurance

Insurance Company *

Policy Number *

Name of Subscriber *

First

Last

Subscriber Date of Birth *

Responsible Party

Are you the responsible party? *

Yes
No

Name *

First

Last

Name of authorizing party if patient is under 18 years of age

Relationship to Patient

Subscriber Date of Birth

Notice of Privacy *

I hereby authorize the use or disclosure of my individually identifiable health information as described in the Privacy Practices disclosure for Green Physical Therapy. A copy of the Notice of Privacy Practices will be provided upon my request.

Lifetime Assignment of Benefits - Information Release - Authorization to Treat *

I authorize payment of medical benefits to Green Physical Therapy for any services furnished. I understand that I am financially responsible for any amount not covered by my insurance carrier. I authorize you to release to my insurance company or its agent information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claim of benefits. I also authorize the Interdisciplinary Team to perform the treatments or procedures approved by my referring physician. I acknowledge that no guarantees, either expressed or implied, have been made to me regarding the outcome of any treatments and/or procedures. I fully understand that it is impossible to make any guarantees regarding the outcome of any medical treatment or procedure.

Cancellation *

I understand that a cancellation made with less than 24 hour notice and or missed appointment will result in a $25 charge and will be billed to me.

	No Pain	1	2	3	4	5	6	7	8	9	Severe Pain
Pain level at its WORST	No PainPain level at its WORST No Pain	1Pain level at its WORST 1	2Pain level at its WORST 2	3Pain level at its WORST 3	4Pain level at its WORST 4	5Pain level at its WORST 5	6Pain level at its WORST 6	7Pain level at its WORST 7	8Pain level at its WORST 8	9Pain level at its WORST 9	Severe PainPain level at its WORST Severe Pain
Pain level CURRENTLY	No PainPain level CURRENTLY No Pain	1Pain level CURRENTLY 1	2Pain level CURRENTLY 2	3Pain level CURRENTLY 3	4Pain level CURRENTLY 4	5Pain level CURRENTLY 5	6Pain level CURRENTLY 6	7Pain level CURRENTLY 7	8Pain level CURRENTLY 8	9Pain level CURRENTLY 9	Severe PainPain level CURRENTLY Severe Pain
Pain level at its BEST	No PainPain level at its BEST No Pain	1Pain level at its BEST 1	2Pain level at its BEST 2	3Pain level at its BEST 3	4Pain level at its BEST 4	5Pain level at its BEST 5	6Pain level at its BEST 6	7Pain level at its BEST 7	8Pain level at its BEST 8	9Pain level at its BEST 9	Severe PainPain level at its BEST Severe Pain

Patient Intake.

Patient Intake Form

Primary Insurance

Secondary Insurance

Responsible Party

Missed Appointment Agreement

COVID-19 Check-In List

Acknowledgement

Schedule an Appointment.

Address

Moreno Valley

Murrieta

Murrieta – Dynamic Fitness

Hemet

Temecula

Phone & Fax

Moreno Valley

Murrieta

Murrieta – Dynamic Fitness

Hemet

Temecula

Office Hours

Moreno Valley

Murrieta

Murrieta – Dynamic Fitness

Hemet

Temecula