New Patient Forms | En Espanol

Patient Information

General Information

First Name:*
Middle Initial:
Last Name:*
Home Address:*
City:*
Select One*
Zip:*
Home Phone:*
Cell Phone:*
Date of Injury:*
Date of Birth:*
Age:*

Patient Employer Information

Employer Name:*
Employer Address:*
City:*
Select a State*
Zip:*
Phone:*

Emergency Information

Contact Name:*
Phone:*
Relationship:

Physician Information

Referring Physician:*
Address:
City:
Select a State
Zip:
Phone:*

Attorney Information

Attorney's Name:
Address:
City:
Select a State
Zip:
Phone:

Insurance Information

Auto Insurance

Are you seeking treatment for an auto accident injury?*
Carrier:
Address:
City:
Select a State
Zip:
Phone:

Medical/Health Insurance Information

Carrier Name:
Address:
City:
Select a State
Zip:
Phone:

Worker's Compensation Information

Is this a work-related injury?*
Workers compensation Ins. Carrier:
Address:
City:
Select a State
Zip:
Phone:

Medical & Injury History

Injury Information

Office Policy

Patient Consent

Please read the following:

I fully understand that I am responsible to Health Point Physical Therapy for all physical therapy bills submitted by them for services rendered to me, and that this agreement is made solely for said therapist’s additional protection and in consideration of their awaiting payment. I further understand that such payment is not contingent on any Settlement, Judgment, or Verdict by which I may eventually recover said fee. I understand that I am financially responsible for all charges whether or not paid by said insurance. I ALSO AGREE TO NOTIFY HEALTH POINT PHYSICAL THERAPY WHEN SETTLEMENT IS MADE SO THEY CAN SUBMIT THE PROPER PAPERS TO MY ATTORNEY IN ORDER TO SPEED UP PAYMENT ON MY ACCOUNT (There is no liability for Worker’s Compensation patients).

I agree with and have read the patient consent statement
(check the box only if you agree).

woman performing physical therapy
patient talking with phyical therapist
picture of the facility: interior.
Therapist working at a computer
a line of balls used for physical therapy

New Patient Forms | En Espanol

Patient Information

Insurance Information

Medical & Injury History

Do you have or had any of the following (check all that apply)?

Office Policy