Date:______________
SS#:______________________________________
Patient Name:______________________________
__________________________________________
Address:___________________________________
City:_________________St:_________Zip:_______
E-Mail:____________________________________
Phone:(_________)__________________________
Cell Phone:(______)_________________________
Sex
Male
Female DOB:_____________
Married
Single
Minor
Divorced
Separated Partnered for _____years
Occupation:_________________________________
Employer/School:____________________________
Employer/School Phone: (______)_______________
Spouse’s Name:______________________________
Spouse’s DOB:_______________________________
Spouse’s Employer:___________________________
Guarantor:
Self
Parent/guardian
Other:___________________________
Guarantor Name:_________________________
Whom may we thank for referring you?
Last
First
Middle Initial
Patient Condition
Reason for visit:______________________________
When did your symptoms appear:_______________
Is the condition getting progressively worse?
Yes
No
Unknown
Rate the severity of your pain:
Type of pain:
Sharp
Dull Throbbing
Aching Burning
Numbness Shooting Stiffness Swelling Tingling
How often do you have this pain?_________________________
Is it constant or does it come and go?______________________
Mark an X on the picture where you have pain, numbness,
weakness or tingling.
______________________________
IN CASE OF EMERGENCY, CONTACT
Name:_________________________________
Relationship:____________________________
1st contact #:(________)___________________
2nd Contact #:(_________)__________________
Insurance Information
Insurance Co.:___________________________
ID #:___________________________________
Group #:________________________________
Patient relationship to insured:______________
DOB of insured:__________________________
Is patient covered by additional insurance?
Yes No
If yes patient’s relationship to insured:
_________________________________________
Insurance Co.:_____________________________
ID #:_____________________________________
Group #:__________________________________
Is this condition due to an accident: Yes No
Date of accident:_________________________
Type of accident: Auto Work Home Other
To whom have you made a report of your accident?
__________________________________________
Phone (_______)____________________________
Attorney name (if applicable):
__________________________________________
Phone (______)_____________________________
Front
Back
Does it interfere with your:
Work
Sleep
Daily Routine
Recreation
Activities or movements that are painful to perform:
Sitting
Standing
Walking
Bending
Laying Down
What treatment have you already received for your
condition? Medication Surgery Physical Therapy
Chiropractic Care None Other:________________
Name of other doctor(s) who have treated your condition:
_______________________________________________
Date of Last: Physical Exam__________ Blood Test__________
Urine Test:_________ Spinal Exam_________ Spinal X-ray_____
MRI, CT or Bone Scan____________________
Primary Doctor:______________________________
Phone :(______)_____________________________
Pharmacy:__________________________________
Medications (prescriptions and OTC)_____________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Allergies:___________________________________
___________________________________________
Health History
__ Abdominal Pain
__ AIDS/HIV
__ Alcoholism
__ Allergies
__ Angina
__ Anxiety
__ Arthritis
__ Asthma
__ Bleeding Disorder
__ Bronchitis
__ Cancer
__Cataracts
__ Chemical Dependency
__ COPD
__ Circulatory Problems
__ Depression
__ Diabetes
__ Dizziness
__ Eating Disorder
__ Emphysema
__ Epilepsy/Seizures
__ Fainting
__ Fever/Chills
__ Fibromyalgia
__ Fractures
__ GERD
__ Headaches
__ Glaucoma
__ Hearing Loss
__ Heart Disease
__ Hepatitis
__ Hernia
__ Herniated Disc
__ High Blood Pressure
__ High Cholesterol
__ Incontinence
__ Joint Replacement
__ Kidney Disease
__ Liver Disease
__ Low Blood Pressure
__ Low Blood Sugar
__ Lyme Disease
__ Memory Loss
__ Migraines
__ Multiple Sclerosis
__ Nausea/Vomiting
__ Numbness/Tingling
__ Osteoporosis
__ Pacemaker/Defibrillator
__ Pinched Nerve
__ Pneumonia
__ Polio
__Stroke
__ Suicide Attempt
__ Thyroid Disorder
__ Tuberculosis
__ Tumors/Growthes
__ Ulcers
__ Urinary Tract Infection
__ Vascular Disease
__ Weight loss/ Gain
__ Whooping Cough
__Glasses/Contacts
__Gout
__ Prostate Problems
__ Prosthesis
__ Psychiatric Care
__ Rheumatic/Scarlet Fever
__ Scoliosis
__ Sexually Transmitted Disease
__ Shortness of Breath
__ Skin Problems
__ Sleep Disorder
__ Guillain-Barre Syndrome
__ Other__________________
_________________________
Pregnant:  Yes  No Due date:_ ________________________
I would rate my health as:
Excellent
Good
Fair
Poor
Have you had any illness in the past 3 weeks? (i.e. cold, flu, bladder/kidney infection)?  Yes  No
If yes, have you had this before in the last 3 months?  Yes  No
Exercise
Work Activity
Habits
__ None
__ Sitting
__ Smoking
Packs/Day____________
__ Moderate
__ Standing
__ Alcohol
Drink/week___________
__ Daily
__ Light Labor
__Caffeine
Cups/Day ____________
__Heavy
__ Heavy Labor
__ High Stress Level
Reason:______________________
Injuries/Surgeries you have had: Description
Date
Falls____________________________________________________________________________________
Head Injuries_____________________________________________________________________________
Broken Bones_____________________________________________________________________________
Dislocations______________________________________________________________________________
Surgeries________________________________________________________________________________
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with_________________________and assign directly to Exeter Physical
Therapy all Insurance benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all
charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
Exeter Physical Therapy may use my health care information and my disclose such information to the above named insurance Company(ies)
and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related
services. This consent will end when my current treatment is completed or one year from the date signed below.
I affirm that I have stated all my known medical conditions. I agree to keep the doctor updated as to any changes in my medical file. I also
understand the any illicit or sexually suggestive remarks made by me will result in immediate termination of any session, I am undertaking and
I will be liable for payment of the scheduled appointment.
_________________________________________________________________
Print Name
_________________________________________________________________
Patient/Guarding Signature
___________________________
Date
________________________________________
Providers Signature
PATIENT NAME: _____________________________________ ACCOUNT# __________________
EXETER PHYSICAL THERAPY FINANCIAL POLICY
We would like to THANK YOU for choosing Exeter Physical Therapy. Exeter Physical Therapy accepts third party payments and will
submit your bills for treatment to the address provided as a courtesy to you. In order for us to bill your insurance company on a
regular basis, we request that you sign this release of information and assignment of benefits (if applicable). Typically, insurances
pay a predetermined amount of our treatment charges; however it is your responsibility to call your insurance company to check on
the coverage provided by your individual policy. As a courtesy to you, we will perform an insurance verification with your insurance
company; however we will not take responsibility for any misinformation that we are given during this process. Therefore, it is
within your best interest to verify your outpatient benefits with your individual insurance plan and to confirm them with our office
prior to initiating treatment.
Please initial after each Acknowledgement
CONSENT FOR CARE AND TREATMENT:
I hereby give written consent for the provision of treatment. I authorize Exeter Physical Therapy to furnish treatment which is
considered necessary and proper in diagnosing or treating my physical condition. __________
FINANCIAL RESPONSIBILITY: I understand that in some instances the applicable insurance may not cover all treatment charges
incurred. I agree to be financially responsible to Exeter Physical Therapy for any medically necessary therapeutic services that are
deemed uncovered by my insurance policy. _________
ASSIGNMENT OF BENEFITS: I hereby authorize payment directly to Exeter Physical Therapy, any benefits payable to me and/or
my qualified dependents under the insurance coverage or Major Medical provisions of insurance coverage identified on bills
submitted by Exeter Physical Therapy for treatment.________
CO-PAYMENTS: I understand that if my insurance plan requires a co-payment for treatment, my co-payment will be collected at
the time of my visit. A surcharge may be applied in order to collect late co-payments. This surcharge will cover expenses incurred
by Exeter Physical Therapy to generate additional bills and/or utilize collection services. _________
LITIGATION ACCOUNTS: I understand that Exeter Physical Therapy will directly bill my appropriate insurance; however I am
responsible for the payment of my treatment, not the entity being sued. Liability action against someone else will not enable me to
refuse payment to Exeter Physical Therapy. _________
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES AND AUTHORIZATION
I hereby acknowledge that I have received a copy of Exeter Physical Therapy’s Notice of Privacy Practices. I also understand that
additional copies of the Notice are available for my review upon request. By way of my signature below, I provide Exeter Physical
Therapy with my authorization and consent to use and disclose my protected health information for the purposes of treatment,
payment and health care operations as described in the Notice of Privacy Practices. ________
CERTIFICATION OF IDENTITY
I certify that I am in fact the individual claim to be. I understand that the knowing and willful use of another individual’s personal
identifying information under false pretenses is a criminal offense. ______
I ACKNOWLEDGE THAT I READ AND UNDERSTAND ALL COMPONENTS OF EXETER PHYSICAL THERAPY FINANCIAL
POLICY AS STATED ABOVE.
Signature of patient or guardian_________________________________ Date________
FOR EXETER PHYSICAL THERAPY OFFICE USE ONLY
VERIFICATION OF IDENTITY
I certify that I have verified the identity of the above named party; verification of identity was made by:
Health Insurance Card that is current _____
Driver’s license or other photo ID that is current ______
Signature of EPT representative ____________________________________Date ______
CONSENT TO PHYSICAL THERAPY EVALUATION AND TREATMENT
I hereby consent to evaluation and/or treatment of my condition by licensed physical therapist employed by or under
contract with Exeter Physical Therapy. The physical therapist has fully explained to me the nature and purposes of the
procedures, evaluation and course of treatment, and has witness my signature of this consent in his or her presence. The
physical therapist has informed me of expected benefits and possible complications or discomfort, which may result from
skilled physical therapy care. In addition, the physical therapist has explained to me the risks of receiving no treatment. The
physical therapist has explained that there is not guarantee that the proposed course of treatment will improve my
condition and that is possible, although unlikely, that the course of treatment may cause additional pain or discomfort or
aggravate my condition. I have been given on opportunity to ask questions, and all my questions have been answered to my
satisfaction. I confirm that I have read and fully understand this consent form.
Patient/relative or guardian ________________________________/_______________________ Signature (Print Name)
Date _____________________________ ______________________________________
(Relationship, if signed by person other than client)
I hereby certify that I have explained the nature, purpose, benefits, risks of, and alternatives to the proposed evaluation and
treatment have offered to answer any questions and have fully answered all such questions. I believe that the
patient/relative/guardian fully understands what I have explained and answered.
Physical therapist_________________________________________Date_________________________
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
I acknowledge that I have received Exeter Physical Therapy. Notice of Privacy Practices for protected health information.
Date: ____________________ Name of Patient: _________________________________________
Print Name _______________________________________________________
Signature of Patient/Personal Representative ________________________________________
Documentation of Good Faith Effort to Obtain Written Acknowledgment
I made a good faith effort to obtain the patient’s written acknowledgment of our Notice of Privacy Practices for protected
health information by (check all that apply):
Showing the patient the Notice of Privacy Practices posted in our office.
Giving the patient the Notice of Privacy Practices to read prior to receiving any treatment for service.
Asking the Patient to sign this Acknowledgment form.
Other (explain it detail)______________________________________________________________
Date: ________________________ Name: ____________________________________
Notes: This written Acknowledgment must be completed no later than the first date of health care services or treatment is
provided to the patient.
Medical Appointment Cancellation Policy
Dear Patient/Client:
We strive to render excellent care to you and the rest of our patients and clients. Your care and treatment is a
priority to us. We also ask that you respect your therapist’s time and expertise as well.
In an attempt to be consistent with this, we have a Medical Appointment Cancellation Policy that allows us to
schedule appointments for our patients, with respect for your time, the next patient’s time, and the doctor and
therapists time.
Our policy is as follows:
We request that you give 24 hours’ notice in the event that you cannot make it to your scheduled appointment. If a
patient misses an appointment without contacting our office, it is considered a missed or “No Show” appointment. A
fee as shown below will be charged to your credit card, depending on the type of appointment missed. Additionally,
if a patient is more than 15 minutes late for an appointment, it will be considered a “no show” appointment, and that
appointment will be rescheduled. Also, if you miss more than 3 appointments, Exeter Physical Therapy reserves the
right to discharge you from the practice for failing to follow treatment recommendations.
If you have any questions regarding this policy, please let our staff know, and we will be happy to clarify the policy for
you.
We look forward to being a part of your continued wellness.
I have read and understand the Medical Appointment Cancellation Policy of Exeter Physical Therapy, and I agree to
be bound by its terms. I am aware that my credit card will be charged for the missed appointment, and I agree to
these terms.
I, _____________________________________________, have received a copy of Exeter Physical Therapy Medical
Appointment Cancellation Policy.
__________________________________
Signature of Patient
___________________________
Witness (EPT Representative)
____________________________
Date
Physical Therapy $75
RECORDS RELEASE AUTHORITY
TO:
I,
HEREBY REQUEST THAT YOU RELEASE
(Patients’ name or guardian)
RECORDS TO:
Exeter Physical Therapy
3933 Perkiomen Avenue Suite 101 Lower Level
Reading, PA 19606
610-401-0365 (p)
610-401-0865(f)
A report of my diagnosis, treatment, prognosis, and recommendations, as well as other data
to
PRESENT
pertinent to your treatment of me from
__All records
__X-rays
__MRI Films
__Bloodwork
.
__Other_______________________
I hereby authorize disclosure of the health information for the above named patient. This authorizations valid for 1 year
From the date of signature. I understand that I may cancel this request with written notification but that it will not effect
Any information released prior to notification of cancellation. I understand that the information used or disclosed may be
subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected
By federal regulations. I understand that the medical provider to whom this is authorized is furnished may not condition
Its treatment of me on whether or not I sign the authorization.
I DO UNDERSTAND THAT THE RELEASING OFFICE/FACILTY MAY CHARGE A FEE FOR THESE RECORDS.
THIS FEE IS NOT IN ASSCIATION WITH EXETER PHYSICAL THERAPY.
Patient's Name PLEASE PRINT
Patient's OR Guardian's Signature
Address
City, State, Zip Code
Patients
DOB:
Patients
SSN:
Please:
Fax Report
X
Mail Films/CD
X