Follow the steps to successfully complete the intake form.

1. Click ‘Get Form’ button to obtain the intake form and open it in the editor.
2. Begin by entering your personal information. This includes your name, age, date of birth, and social security number. Select your gender and provide an email address if you wish to receive updates.
3. Fill out your mailing address, including city, state, and zip code. Don’t forget to provide both your home phone and cell phone numbers, along with your employer's details, including their contact number.
4. Indicate your emergency contact information. Provide the contact's name, relationship to you, and their phone number.
5. Complete the guarantor or sponsor information section. Here, you will enter the name and relationship of the person responsible for payment, along with their relevant details, similar to your personal information.
6. In the treatment reason section, specify the body part you are seeking treatment for. Check the appropriate box regarding your injury side and provide dates for your injury and any surgeries, if applicable.
7. If applicable, provide workman’s compensation or motor vehicle accident information, including your insurance company and claim number, along with the adjuster’s details.
8. Review and acknowledge the financial responsibility statement, authorizations for treatment, and the release of information. Ensure that all personal and medical details are accurate before signing.
9. Complete the self-evaluation questionnaire by answering the questions related to your condition, pain levels, past medical history, and current medications.
10. Finally, save your changes, and choose to download, print, or share your completed form as needed.

Start completing the MT Lone Peak Physical Therapy Patient Intake Form online today to ensure you receive timely and effective care.