302 West Main Street, Suite 204, Avon, CT 06001

Phone: 1-860-679-0430

Fax: 1-860-679-0431

61 Maple Avenue, Suite 2, Canton, CT 06019

Phone: 1-860-352-2463

Fax: 1-860-352-8247

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Patient Intake Form

Printable Form at Bottom of Page

Name:___________________________________________________       Date of Birth: _________________________________

Street Address:______________________________________________________________________________________________

City:________________________________________________    State: __________    Zip Code:__________________________

Home Phone:______________________________________    Cell Phone:___________________________________________

Email Address: ______________________________________________________________________________________________

Occupation: ___________________________________________________    Marital Status (circle one):   M  S  D  W

 

Emergency Contact: __________________________________________    Phone: ___________________________________

Relationship to Patient/Client: _____________________________________________________________________________

Primary Care Doctor: ________________________________________    Phone:_____________________________________

Specialist Doctor:_____________________________________________    Phone:____________________________________

 

How did you hear about Magna Physical Therapy?_____________________________________________

Would you like information about our Personal Training, Massage Therapy, or Group Fitness/Pilates Programs?   Yes   No

Do you wish to speak with a social worker at this time?   Yes   No

 

AUTHORIZATION OF PAYMENT:It is our policy that office visits are paid for at the time services are rendered, this includes co-payments and deductibles.  Once your insurance carrier processes your claim we will bill you for any remaining patient responsibility deemed by your insurance carrier.  As a courtesy to you, we have verified the following coverage is offered to through your current insurance carrier:

COINSURANCE/CO-PAY: _________________________________________________

DEDUCTIBLE: _____________________________________    AMOUNT REMAINING: ________________________________

MAXIMUM PHYSICAL THERAPY BENEFIT: ___________________________________________________________________

I hereby authorize Magna Physical Therapy to release all information necessary, including medical records, to secure payment.  I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees. 

*Note: Magna Physical Therapy does not accept responsibility for any incorrect information given by you or your insurance carrier regarding your insurance benefits or benefit plans.

 

Client/Guardian Signature: ______________________________________________    Date: _________________________

CONSENT TO TREATMENT:I agree and give my consent for Magna Physical Therapy to furnish rehabilitative care and related treatment to be considered necessary and proper in diagnosing or treating my physical condition.  In so doing, I understand and acknowledge that such rehabilitation and related services may involve bodily contact, touching and/or direct contact of a sensitive nature.

                                                                                                                        Initials: ______________________

 

LIABILITY:I know and agree that Magna Physical Therapy is not responsible for loss or damage to personal valuables that are brought with me during treatment at the facility.

                                                                                                                        Initials: ______________________

 

WAIVER AND RELEASE:I hereby release Magna Physical Therapy & Sports Medicine Center, LLC and its affiliated entities, employees, trustees and their respective representatives and agents from all claims, liabilities, and causes of action arising from or associated with my participation in this program.

                                                                                                                        Initials: ______________________

 

MEDICAL WAIVER:I understand that providing Magna Physical Therapy staff with current information about changes in my health, which includes any illness or symptoms I experience in the performance center or at home, is essential for the staff to determine if any modifications need to be made in my exercise program.  I understand that if I do not inform the Magna Physical Therapy staff that I may be putting myself at risk for injury or serious medical problems.  I understand that the staff has the right to address concerns about my health with my physician and may ask to temporarily discontinue or modify my treatment until my physician evaluates my condition and provides recommendations for care.

                                                                                                                        Initials: ______________________

 

NOTICE OF PRIVACY PRACTICES:  I acknowledge receipt of Notice of Privacy Practices/Policies.

                                                                                                                        Initials: ______________________

 

CANCELLATION POLICY:I understand that I will be charged a $25.00 cancellation/No Show fee if I fail to keep an appointment without at least 24 hour notification.

                                                                                                                        Initials: ______________________

 

 

I, the undersigned, certify that all the information provided herein is true and correct to the best of my knowledge. Ihave reviewed the above policies and do hereby agree to abide by them to the best of my abilities.

 

Client/Guardian Signature: ______________________________________________    Date: _________________________

 

 

To print Patient Intake Form click here: