Get Mt Lone Peak Physical Therapy Patient Intake Form 2021-2025

The MT Lone Peak Physical Therapy Patient Intake Form is an essential document that collects important information regarding your medical history and treatment needs. This guide offers clear and structured instructions on how to properly complete the form online to ensure a smooth patient intake process.

Follow the steps to complete the patient intake form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin by filling in your personal information. Include your full name, age, date of birth, and social security number. Select your sex and provide your email address if you would like to receive updates.
3. Enter your mailing address, including city, state, and zip code. Provide your home and cell phone numbers, along with your employer's name and contact number.
4. Complete the emergency contact section by listing a person you can be reached by, including their name and phone number.
5. Move to the guarantor/sponsor information. If you are not the financial guarantor, fill out the details regarding the individual who is responsible for payment.
6. Indicate why you are seeking treatment by specifying the body part affected and the nature of your injury. Ensure to include the dates relevant to your injury or surgery if applicable.
7. If this form pertains to workman’s compensation or a motor vehicle accident, provide the necessary insurance company information, the adjuster's name, claim number, and phone details.
8. Read through the financial responsibility clauses and ensure you acknowledge your understanding of payment agreements, cancellation policies, and consent for treatment.
9. Authorize the release of your medical information by signing or initialing where required. This ensures that the physical therapy facility can obtain and share necessary health information.
10. Complete the patient self-evaluation questionnaire, answering questions about your condition and needs. This includes history of the issue, activities that aggravate the symptoms, pain levels, and any medications currently being taken.
11. After completing all sections, review the form for accuracy. Save changes, download it for your records, or print it if necessary before final submission.

Start filling out the MT Lone Peak Physical Therapy Patient Intake Form online today to ensure your medical needs are met efficiently.