Get New Patient Form - Landers Physical Therapy

Completing the New Patient Form for Landers Physical Therapy online is a straightforward process designed to facilitate your entry into our care. This guide will provide clear and detailed instructions to help you navigate each section of the form efficiently.

Follow the steps to effectively complete your New Patient Form.

1. Click the ‘Get Form’ button to access the New Patient Form and open it in your preferred document editor.
2. Begin by entering the date at the top of the form. Please ensure you input the current date to maintain accuracy.
3. Fill in your name with the appropriate fields: First Name, Middle Initial, and Last Name. Ensure accuracy as this will be used for your medical records.
4. Provide your complete mailing address, including street, city, state, and zip code. This information is necessary for correspondence and billing purposes.
5. Input your phone numbers (Home, Mobile, and Work) and email address. This information will help facilitate communication regarding your appointments.
6. Enter your social security number, date of birth, age, and sex as required. This information assists in identifying your account and managing records.
7. Designate an emergency contact by providing their name and phone number. This is important for any potential emergencies during your treatment.
8. Indicate whether you currently receive or have recently received home healthcare services by selecting 'Yes' or 'No'. This will inform your care plan.
9. Fill out how you heard about the clinic. This helps us understand our outreach effectiveness.
10. List the name of your referring physician, if applicable, and if there is a next appointment scheduled, please provide that date.
11. Select your personal status (Married, Single, Divorced, etc.), employment status, and employer’s contact information if applicable.
12. Detail the type of injury you have (Work, Auto, Home, or Other). Include the date of the injury and, if it was a work-related injury, provide the employer’s name and contact.
13. If applicable, include details regarding any attorney involved in your case.
14. Fill in information about your insurance policy holder and the name of your insurance company. Be sure to note whether it is Group/Personal, Medicare, or Worker’s Comp.
15. For any release of protected health information (PHI), complete the required sections, including your name, date of birth, address, and the purpose for release.
16. After completing all sections, review your entries for accuracy. Once confirmed, you can save changes, download, print, or share the form as needed.

Complete your New Patient Form online to ensure a smooth experience as you start your physical therapy journey.