New Patient Intake Form

Complete the following form prior to your visit.

New Patient Intake

First Name

Last Name

Home Phone

Cell Phone

Street Address

City

State

Zip Code

Date of Birth

SSN

Employer

Spouse's Name

Spouse's Cell Phone

Insurance Card (Front)

Upload File

Insurance Card (Back)

Upload File

Secondary Insurance Card (Front)

Upload File

Secondary Insurance Card (Back)

Upload File

Mother/Guardian Name

Mother/Guardian Phone

Mother/Guardian Address

City

Region/State/Province

Postal / Zip code

Father/Guardian Name

Father/Guardian Phone

Father/Guardian Address

City

Region/State/Province

Postal / Zip code

Emergency Contact Name

Emergency Contact Phone

I authorize Columbia Physical Therapy, Inc. P.S. to use and disclose health and medical information for the purposes of treatment, payment and health care operations. Under all circumstances I assume final responsibility for my account understanding that in the event my account becomes delinquent, I agree to pay accrued finance charges, court costs and attorney fees. I consent to physical therapy services prescribed by any physician. I authorize payment of medical benefits by my insurance company to Columbia Physical Therapy, Inc. PS, for
services rendered. I have received this practice’s Notice of Privacy Practices written in plain language.

Patient Signature

Date

What do you authorize?

All medical, billing, and appointment information

Appointment information only

Authorized Person #1

Authorized Person #2

Authorized Person #1 Relation

Authorized Person #2 Relation

Signature for Medical Release Authorization

Anything else we should know?

Thanks for submitting! Please let us know what questions you have, otherwise we'll look forward to seeing you soon!

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