Intake Form
1. Consent to Treatment
1. I have presented myself to this facility for therapy treatments and consent to the care (history, physical
examination, treatment, etc.) that will be provided by my therapist. I realize I have the right to refuse any
treatments or procedures to the extent permitted by law. I acknowledge that the delivery of health care
does not guarantee results of any treatments at this facility. I understand that information from any
medical record(s) kept by this facility may be used for educational, administrative, and/or facility
approved purposes when my personal identity will not be revealed.
2. I hereby authorize OMEGA SPORTS + RECOVERY to provide any physical therapy services or related
services as deemed necessary by the physical therapist(s). I consent and authorize OMEGA SPORTS
+ RECOVERY to release all information contained in my medical and financial records, including
diagnosis and test results, to any specialist involved in my care including any person or entity
responsible for paying or processing for payment of any portion of my healthcare bill(s) governmental or
accrediting agencies any other health care provider to which I am referred or transferred for care utilizing
this information for quality management, peer review and or outcome analysis any other person or entity
as required or allowed by state and/or federal law This consent applies to all records created in the
course of and relating to this healthcare. To provide the practitioners who will treat me during my care
with an access to my prior medical history, I also consent and authorize any health care provider to
release medical information contained in my medical records from prior treatment that is relevant to my
current care and treatment. If I am the patient or the patient’s legal guardian, I also consent to release
billing information and medical records to the patient’s primary care physician (PCP) and his/her medical
group. This release shall remain valid until I notify the company, in writing, of my desire to revoke it
2. Photo/Video Authorization
1. I grant to OMEGA SPORTS + RECOVERY, and its representatives and employees (collectively the
“Company”) the right to take photographs and\or videos of me in connection with my participation in
physical therapy services. I authorize the Company, to copyright, use and publish the same in print
and/or electronically. I agree that the Company may use such photographs of me with or without my
name and for any lawful purpose, including for example such purposes as publicity, illustration,
advertising, and Web content and waive any right to compensation therefore. I understand that I may
revoke this authorization but only in writing delivered to the clinic office manager. I understand that if I
choose to revoke this Authorization, the revocation will not be effective for any uses and/or disclosures
of my protected health information that have already been made in reliance on this Authorization.
◘ Agree or ◘ Decline
3. Notice of Privacy Practices
1. By signing this form, I acknowledge that Omega Sports + Recovery has made its’ Privacy Notice
available to me, which explains how my health information will be handled in various situations. I
understand that I may discuss my concerns and/or any questions I have concerning this Privacy Notice
with OMEGA SPORTS + RECOVERY representatives.
4. Personal Valuables
1. Thereby release OMEGA SPORTS + RECOVERY and its associates of responsibility for loss or
damage to personal property, including but not limited to clothing, money, or other valuables kept in my
possession during my care.
5. Financial Agreement
1. I understand and agree that I am totally responsible and liable for payment of all charges assessed for
professional services rendered and will pay any sum due upon demand. I understand that OMEGA
SPORTS + RECOVERY is a cash-based practice and does not deal with insurance agencies regarding
reimbursement for services. I agree to pay OMEGA SPORTS + RECOVERY the full and entire amount of all
bills incurred by me or the above named patient It is my responsibility to obtain receipt from OMEGA
SPORTS + RECOVERY and to submit a claim to my insurance for reimbursement. If insurance
company denies reimbursement or does not give back the desired amount, I understand that OMEGA
SPORTS + RECOVERY is not liable and will not refund me for my payment or services. I understand
that payment for services is due at check-in or online via www.omegathlete.com.
6. Release of Information
1. I authorize the following individuals to receive information regarding my diagnosis, treatment, and billing:
1. (First & Last name, Relationship):
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
7. Accidental Exposure of the Healthcare Worker:
1. I understand that Texas law provides, if any healthcare worker is exposed to the patient’s blood or other
bodily fluid, that OMEGA SPORTS + RECOVERY may refer you out to perform test(s) on the patient’s
blood or other bodily fluid to determine the presence of human immunodeficiency virus (HIV, the virus
associated with AIDS). I consent to the testing for other communicable diseases, including but not
limited to hepatitis and syphilis, in the event of an accidental exposure to a healthcare worker. I
understand that such testing is necessary to protect those who will be caring for the patient while a
patient of OMEGA SPORTS + RECOVERY. If you refuse to be refferred out, you will be held liable for
any occurring medical bills for the healthcare professional.
Authorization
I acknowledge, as indicated by my signature below, that I have read and fully
understand this intake form. By signing this form, I am acknowledging my
understanding of the "Notice of Privacy Practices" and authorizing persons listed on
the Information Release to receive my health information. I have reviewed this office's
Notice of Privacy Practices, which explains how my medical information will be used
and disclosed. I understand that I am entitled to receive a copy of this document.
I, _________________ the parent/legal guardian of, ___________________,
authorize physical therapy treatment to be administered by OMEGA SPORTS +
RECOVERY
Patient Name (please print):
____________________________________________
Patient or Guardian Signature:
_____________________________________________
Date of Authorization: ___________________________
Medical Questionnaire Form
Patient Name:___________________ Age:____ Telephone Number:______________________
Previous Physical Therapy: Yes or No (Circle One), Previous X-Ray, MRI, CT or_______(Circle)
Chief Complaint:____________________ Date of Injury:_________ Date of Surgery:__________
Past Surgeries (DATE):
______________________________________________________________________
Medications:
______________________________________________________________________
On the body diagram below, please indicate where your symptoms are located at the present time.
Please do not indicate areas that are not related to your present injury or condition.
Key: pins/needles = 000 burning = xxx deep ache = zzz sharp/stabbing = ///
What increases pain?
________________________________________________________________________
What decreases pain?
________________________________________________________________________
Rate your pain at its worst, average and best; 0 no pain, 10 worst possible pain:
Worst:
Average:
Best:
Are your symptoms Constant or Intermittent (Circle One)
Describe your symptoms:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
____________________________________________