If you are a new patient, please download our new patient packet, or you can fill out the forms below and they will be sent to our office. All information is confidential
Is your injury the result of an accident? YesNo If yes, was it work relatedmotor vehicle accident Other
Appointment Reminders will be sent via Text Messaging. Please state your service provide
Ins Co Phone Number
Policy ID Number
Policy Holder’s Name
Date of Birth
Relationship to Patient
Worker’s Compensation Carrier Address:
Case Manager Phone
Date of Injury
Employer at time of injury
Employer Phone Number
Do you have any previous history of:
Which of the following aggravates your condition?:
What eases your symptoms?
Have you been admitted to the hospital or had any surgical procedures during the last 5 years: YesNo
What was this condition? :
Is this condition the reason you were referred to physical therapy? : YesNo
Have you received any physical therapy treatments during the past 5 years? : YesNo
If yes, for what condition and was the treatment effective?
Have you had any other previous medical problems or surgeries? : YesNo
If yes, please specify:
If yes, please specify:
Have you had any previous orthopedic problems? YesNo
Medications? What type and what for?
What types of activities?
Name of your orthopedic and/or primary doctor?
*By typing in the field above, you authorize this e-signature to be valid and accurate.
Patient Name:Please mark the diagram with “xx” where your pain typically presents:
On a scale of 1 to 10, (1 being minimal pain and 10being excruciating), please rate your overall pain:
Financial Policy and Patient Responsibility Acknowledgement of Receipt of Notice of Privacy Practices
Rehab Plus Sport Therapy is committed to providing our patients with the highest quality care.We thank you for taking the time to read and understand our policy.
It is the Patients Responsibility:
If cancelling the appointment and without such notice, the patient will be charged $50.00.
It is Rehab Plus Sport Therapy’s Responsibility:
I have read and understand the above financial policy. I understand that, regardless of my insuranceclaim status or absence of insurance coverage, I am ultimately responsible for the balan
ce on my account for any services rendered. I authorize my insurance carrier(s) to make payment directly to Rehab Plus Sport Therapy (Jeff Kitchen, Inc.). Any payments made to me by third party payer services provided by Rehab Plus Sport Therapy (Jeff Kitchen, Inc.) will be immediately (within 5 days) transferred to Rehab Plus Sport Therapy (Jeff Kitchen,Inc.).
I acknowledge receipt of HIPAA compliant Notice of Privacy Practices.
By signing above, you, as the patient or responsible party, agree to the terms and conditions listed under “Financial Policy Acknowledgement” andAssignment of Benefits”.
Any unilateral alteration, strikeover or modification to the preprinted text or line entries of this document and legal agreement shall be of no effect whatsoever, and at Jeff Kitchen Inc.’s sole discretion, may render this document invalid.