I would like to personally thank you for choosing us to serve you for your physical therapy
needs. Our team takes pride in offering a professional and friendly environment for you to
rehabilitate. Our goal is to create a safe and comfortable environment for all to heal using the
most up-to-date and advanced treatment techniques to provide a quick recovery.
If you have any questions in regards to physical therapy one of our licensed therapists would be
happy to speak with you. Please call the front desk to arrange this. Billing questions can be addressed to
Judy at (810) 385-7405.
Before your first visit there are a few things we would like you to be aware of:
 If you are coming to be evaluated for the neck or shoulders please consider a tank top or sports
bra so we have access to your shoulder and neck.
 If you are coming to be evaluated for low back, hips, knees, or feet please bring loose fitting shorts
(If you do not have them, we can provide them for you).
 The first visit will last about an hour and will include a thorough examination, a computer survey,
and in many cases exercise to be done at home.
 A physical therapy program may last 4-6 weeks depending on you needs, so bring your calendar to
set up your appointments.
 Remember your prescription for physical therapy if you have one, an updated health history form,
current medication list, your insurance card and a current ID.
 Please arrive 15 minutes early.
We look forward to working with you to achieve your goals,
Markus Munger PT, Cred. MDT
Clinton Township
44925 Morley Drive
Clinton Township, MI 48036
586.846.4320
Fort Gratiot
4351 24th Ave. Suite 1
Fort Gratiot, MI 48059
810.385.7405
First Name: __________________________________ MI: ______ Last Name: ______________________________________ Date: ______________
Address: ______________________________________________________ City: _________________________ State: ________ Zip: _______________
Home Phone: (_______)___________________ Work Phone: (________)__________________ Cell Phone: (_______)_____________________
SS#: __________________________________ E-mail Address: _________________________________________________________________________
How did you hear about us? ____________________________________________________________________________________________________
Date of Birth: __________________________________________ Age: ___________________ Sex: M F Marital Status: S M D W
Have you had therapy before? Yes No if yes, Describe: _____________________________________________________________________
Have you received Home Care in the last year? Yes No if yes, Date of Discharge: _________________________________________
Update by e-mail
 Yes  No Emergency Contact: (_______)_________________________ Name: ________________________________
Date of injury or onset: ________________________
Birth date: _________________ SS#: ____________________
Cause of injury: _________________________________
Primary Insurance: __________________________________
___________________________________________________
Insured Name: ________________________________________
Injury Area: _____________________________________
Group #: _____________________ ID#: ____________________
Physicians Name: ______________________________
Address: __________________________________________ ____
Phone: (____)_____________ Last seen: ____________
City: _________________________________ State: _________
Physicians Address: ____________________________
Zip: ________________Phone: (______)__________________
_____________________________________________________
Insured Employer: __________________________________
Responsible Party: _____________________________
Relationship: ___________________________________
Address: ________________________________________
___________________________________________________
City: _________________ Phone: (_____)____________
Relationship to insured: _____________________________
Insured D.O.B: ________________________ Sex: M F
Secondary Insurance: ________________________________
Insured Name: ________________________________________
Group #: _____________________ ID#: ____________________
Address: _______________________________________________
Employer: _______________________________________
City: ___________________________________ State: _________
Occupation: _____________________________________
Zip: ________________Phone: (_____)______________________
Employer Address: _____________________________
Insured Employer: ______________________________________
___________________________________________________
Relationship to insured: _______________________________
Employer Phone: (______)_______________________
D.O.B of insured: ________________________ Sex: M F
Ins. Holders Name: _________________________________
Patient Name: ______________________________________ Date of Birth: ___________________________
Do you have or have you ever had any of the following conditions? (Check all that apply)
 Pregnant
 Currently Pregnant
 Back pain
 High Blood Pressure
 Osteoporosis
 Arthritis
 Controlled
 Anxiety or Panic Attacks
 Cancer
 Uncontrolled
 Kidney problems
 Visual Impairments
 Low Blood Pressure
 Incontinence
 Heart Condition
 Thyroid Problems
 Respiratory Problems
 Congestive Heart Failure
 Diabetes
 Asthma
 Heart Attack
 Controlled
 Controlled
 Atherosclerotic Disease / CAD
 Uncontrolled
 Uncontrolled
 Angioplasty
 Depression
 COPD
 Valvular Disease
 Dizziness/Fainting
 Controlled
 Stents
 Fractures
 Uncontrolled
 Arrhythmia
 Headaches
 Emphysema
 Coronary Artery Bypass Graft
 Hepatitis/HIV/AIDS
 Bronchitis
 Angina
 Kidney Problems
 Pacemaker
 Prior Surgeries
 Controlled
 Stroke
 Recent Pneumonia
 Uncontrolled
 Peripheral Artery Disease
 Neurological diseases
 Seizures
 Allergies: _______________
If checked any above, explain:
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
What specific activities are you having difficulty with?
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
What are the personal goals you hope to achieve from therapy?
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Have you had prior physical/occupational therapy for this condition?  YES  NO
What was done, what were the results?
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Patient Name: ______________________________________ Date of Birth: ___________________________
Please Initial Each as Applicable:
CONSENT TO TREATMENT: I consent to rehabilitation and related services at Munger Physical Therapy. In
so doing, I understand, acknowledge and affirm that such rehabilitation and related services may involve
bodily contact, touching, and/or direct contact of sensitive nature.
INIT: _________
TREATMENT OF MINORS: I, as a parent/guardian of a minor receiving treatment hereunder, do hereby
agree and understand that I have been advised to remain on the premises during any such treatment, and
waive any claim I may have resulting from failure to do so.
INIT: _______
LIABILITY: I know and agree that Munger Physical Therapy is not responsible for loss or damage to
personal valuables.
INIT: _______
WAIVER AND RELEASE: I hereby release, discharge and acquit Munger Physical Therapy, it’s agents,
representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of
action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or
medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or
urgent care services.
INIT: _______
AUTHORIZATION OF PAYMENT: I hereby assign all benefits directly to Munger Physical Therapy and also authorize
release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise
permitted or required in the Notice and Privacy Practices. I understand fully that in the event my insurance
company or financially responsible party does not pay for the service I receive, I will be financially responsible for
payment.
INIT: _______
NOTICE OF PRIVACY: I acknowledge receipt of Notice of Privacy Practices.
INIT: _______
I certify that all of the information provided herein is true and correct.
Patient/Guardian Signature ______________________________________________ Date: ________________________________
Witness Signature _________________________________________________________ Date: ________________________________
Notice of Privacy Practices
This is summary describes how we use and share information about you. This summary also describes how you may see
and get copies of this information.
We might use or share information about you for
Treatment- Such as when our Physical Therapist discusses your care.
Payment- Such as when we bill your insurance company for services provided to you.
Operations- Such as when we work to make the quality of care we provide better. When we share information
to protect the health and safety of others or you or when we respond to court requests. We also may
send you appointment reminders.
How you may see and get copies of this information
You have the right to:
1. Ask for restrictions on the way we use and give out your information. However, we are not required to do what
you ask.
2. Obtain and inspect a copy of your health record.
3. Add information to your health record.
4. Ask that your health information be sent to alternate address or that you be called at an alternate phone number.
5. Change your mind if you told us we could use or share your information for reasons other than those listed
above.
6. Get a list of the dates we gave out your information. It will be a list of the dates that the law requires us to keep a
record of giving out your information.
Our Commitment to Respect Privacy
Munger Physical Therapy is required to:
1. Keep your information private.
2. Let you know if we cannot do what you have asked us to do with your information.
3. Try to reach you at another location or phone number, if you ask us to do so.
4. Use and/or give out your information as listed above and as the law permits, unless we have your permission to
do more.
5. As we serve our patients, we may change what we do with your information. If we make changes, we will give
you a new notice the next time you visit us.
Complaints
If you believe that your privacy rights have been violated, please contact our privacy officer.
Munger Physical Therapy
Attn: Privacy Officer
4351 24th Ave, Suite 1
Fort Gratiot, MI 48059
Email: [email protected] and/or [email protected]
Medication List
Patient Name:_________________________________________
Name of Medication
Birth Date:____________________
Date:
Dosage How Administred When to take Why take it? Physician
Over-the-counter Medications (Check all that applies)
Allergy relief, Antihistamines
Antacids
Cold / Cough Medication
Laxatives
Asprin / Other relief for pain
Multivitamin
Patient Signature:______________________________________
Diet Pills
Sleeping Pills
Others:____________________
Reviewed By:_____________________________________
Cancellation/No Show Policy
Cancellations need to be telephoned in by 5 PM the previous day before scheduled
appointment. Failure to show for appointments will be charged a $30.00 no show fee that will
be the patient’s responsibility. This policy is being put into place due to frequent cancellations
and no shows. These appointments then cannot be filled by patients who are in need of our
services.
Thank you in advance for your cooperation.
Signature
Printed Name
Date