Get New Patient Registration Form - Physical Therapy...

Completing the New Patient Registration Form for Physical Therapy is an important step in your journey towards recovery. This guide provides clear and informative instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete your registration form smoothly.

1. Click ‘Get Form’ button to obtain the form and open it in an appropriate editor.
2. Begin with the Patient Demographic Information section. Fill in your first name, middle initial, last name, date of birth, gender, social security number, marital status, and emergency contact information, including their name, relationship to you, and phone number.
3. Next, fill in your Patient Contact Information. Provide your street address, apartment/unit number (if applicable), city, state, home and work phone numbers, email address, and preferred forms of contact by selecting two options from the available choices.
4. In the Insurance Information section, enter the subscriber's name, date of birth, relationship to the subscriber, employer name, employer phone number, and occupation. Remember to have the front desk copy your insurance card when you arrive.
5. Move on to the Patient Symptoms section. List your referring doctor and primary care doctor, date of injury/onset, top recreational activities, and describe how your injury occurred and your symptoms. Rate your pain on a scale from 0 to 10 and shade the areas of your symptoms on the provided diagram.
6. Specify what makes your symptoms feel better or worse in the designated fields, and then certify the accuracy of your information by signing and dating the provided space.
7. Continue to the Patient Medical History section. Mark any relevant medical conditions you currently have or have had in the past. Include any surgeries and list current medications, noting anything else relevant to your medical history.
8. In the Patient Acknowledgement and Consent Form section, list authorized individuals who may access your health information, or indicate none if applicable. Sign and date this section.
9. Read and understand the acknowledgment and consent of terms and policies, checking the appropriate boxes, signing, and dating where prompted.
10. Finally, complete the Assignment and Release section by authorizing payment of your insurance benefits directly to Physical Therapy Innovations, Inc. Sign and date the document.

Begin completing your New Patient Registration Form online to ensure a seamless experience.