Follow the steps to successfully complete the form

1. Press the ‘Get Form’ button to obtain the form and open it in a digital environment.
2. Begin by entering your personal details in the 'Patient Name' section, including first, middle, and last name.
3. Input your Social Security Number (SSN) in the designated field.
4. Fill out your address, including city, state, and zip code, followed by your home, cell, and work phone numbers.
5. Enter your birthdate and age in the appropriate fields.
6. Indicate your gender by selecting either 'Male' or 'Female.'
7. In case of an emergency, provide the name and phone number of a contact person.
8. Select how you heard about the clinic by circling one option, such as Referring Doctor, Insurance, Friend, Internet, or Other.
9. If the patient is a minor, complete the 'Responsible Party' section, ensuring the information matches the person responsible for the account.
10. Describe your condition by providing the date you first noticed any pain or functional problems, including any recent flare-ups.
11. Indicate whether the injury is work-related or due to an auto accident, and provide relevant dates and details.
12. In the medical history section, indicate any diagnoses by checking all that apply, including conditions like diabetes or heart conditions.
13. List any medications you are currently taking and their dosages in the designated area.
14. Articulate your goals for physical or occupational therapy in the provided space.
15. Review the authorization and release statement, ensuring that you understand your responsibility for providing accurate information.
16. Sign and date the form where indicated to complete the submission.
17. Once you have filled out all sections, you can save changes, download, print, or share the finished form.

Complete your documents online today for a smoother healthcare experience.