New Patient Intake Form

Complete the following form prior to your visit.

New Patient Intake Form

First name

Last name

Cell Phone

Home Phone

Street Address

City

State

Zip Code

Date of Birth

SSN

Employer

Spouse's Name

Spouse's Phone

Insurance Card (Front)

Upload Photo

Upload Image (15MB max)

Insurance Card (Back)

Upload Photo

Upload Image (15MB max)

Mother / Guardian Name

Father / Guardian Name

Emergency Contact Name

Mother / Guardian Phone

Father / Guardian Phone

Emergency Contact Phone

I authorize Premier Physical Therapy 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 Premier Physical Therapy for services rendered. I have received this practice’s Notice of Privacy Practices written in plain language.

Patient Signature

Select a date

What do you authorize? Required

All medical, billing, and appointment information

Appointment information only

Authorized Person #1 Name:

Authorized Person #2 Name:

Authorized Person #1 Phone:

Authorized Person #2 Phone:

Signature for Medical Release Authorization

Today's Date

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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