Register Online - Furnace Brook Physical Therapy

Patient Information

Patient Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Home Phone

Cell Phone

Date of Birth

SS #

Sex

Male
Female

Referring Physician

Primary Physician

Diagnosis

List your present Injury

Employer

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone

Emergency contact

Emergency Contact Phone

Is this injury the result of an accident?

No
Yes

If Yes

Is this a workers comp claim
Is this auto related

If yes, Date of Injury

Have you had Physical Therapy before?

Yes
No

If yes, where?

If yes, when

If yes, insurance type

Primary Insurance Information

Insurance Carrier Name

Insurance Carrier Phone

Group Policy Number (if Available)

I.D #

Subscriber Name

Subscriber Date of Birth

Relationship to patient

Self
Spouse
Parent
Other

If Other please list relationship

Copay / Coinsurance Amount

Secondary Insurance Information

Secondary Insurance Carrier

Secondary Insurance Carrier Phone

Secondary Group Policy Number (if Available)

Secondary I.D #

Secondary Subscriber Name

Secondary Subscriber Date of Birth

Secondary Relationship to patient

Self
Spouse
Parent
Other

If Other please list relationship (copy)

Benefit

Workman's Compensation Information - If applicable

Insurance Company Name

Claim #

Address

Address Line 1

Address Line 2

City

State

Zip Code

Adjustor Name

Adjustor's Phone

Employer at time of the Injury

Employer's Phone

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer's Fax #

Automobile Insurance Information (if applicable)

Insurance Company Name

Claim #

Insurance Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Name of Insured

Relationship to Insured

Adjustor's Name

Adjustor's Phone

Available PIP

Medical History

Could you be pregnant?

Yes
No

Do you now or have you ever had any of the following?

Arthritis

Yes
No

Osteoperosis

Yes
No

High Blood Pressure

Yes
No

Heart Disease

Yes
No

Heart Attack

Yes
No

Pacemaker

Yes
No

Vascular Disease

Yes
No

Stroke

Yes
No

Asthma

Yes
No

Shortness of Breath

Yes
No

Chronic Cough

Yes
No

Fainting Spells

Yes
No

Diabetes

Yes
No

Hypersensitivity to Heat or Cold

Yes
No

Swelling in the Ankles

Yes
No

Seizures/Epilepsy

Yes
No

Deep Vein Thrombosis

Yes
No

Metal Implants

Yes
No

Cancer / Tumor

Yes
No

Recent Weight Loss / Gain

Yes
No

Current Infection(s)

Yes
No

Tuberculosis

Yes
No

Hepatitis

Yes
No

Thyroid Problems

Yes
No

Headaches

Yes
No

Head Injury / Concussion

Yes
No

Hernia

Yes
No

Kidney / Bladder Problems

Yes
No

Previous Fractures

Yes
No

Previous Surgeries

Yes
No

Hearing Loss

Yes
No

Depression

Yes
No

Anxiety

Yes
No

Substance Abuse

Yes
No

Allergies

Yes
No

Other

Yes
No

If you answered "yes" to any of the above, please explain and provide approximate date(s)

Please list all medications you are currently taking

The information above is correct to the best of my knowledge

Signature

(You will be asked to sign this section of the form in person on your first visit)

Today's Date

Your Name:

I am responsible for understanding my own insurance coverage. I agree to contact my insurance carrier to find out if my treatment is covered and to take such steps as required to qualify my treatment for coverage. I agree to inform FBPT of any changes to my insurance.
If FBPT does not receive insurance authorization for my treatment, I understand that I may sign an insurance waiver, which is valid for one treatment session.
I agree to pay any received co-payment at every visit, or in advance.
I will pay for any non-covered medical supplies (ie. Theratubing, Ionto pads) at the time of the disbursement.
We request a 24 hour notice in the event of cancellation. I understand that treatment might be terminated if I cancel or no show for 3 appointments without rescheduling. We only treat patients who help us get them well.
If my check is returned to FBPT for insufficient funds, I agree to pay applied bank charges in addition to the amount of the check.
Consent to Treat
I authorize FBPT to evaluate and treat my injury and perform any therapeutic procedure or treatment that is consistent with my diagnosis. I authorize FBPT (including students in training) to administer treatment under the direction and supervision of the physical therapy. I will be given the opportunity to ask questions regarding my treatment, if they so arise, and that my physical therapist will be available to answer my questions. I understand and am informed that, as in the practice of medicine, physical therapy may have some risks and my condition may worsen on rare occasions. No guarantee or promise has been made to me concerning the results of treatment. I understand that I can terminate any treatment at any time if I so desire.
Payment Guarantee
In consideration of the services rendered and to be rendered by FBPT, I expressly guarantee payment of my account and agree to pay any charges left unpaid in whole or in part by my insurance carrier, and that I am ultimately responsible for account totals and balance regardless of the disposition of the insurance carrier.
Assignment of Benefits
I authorized payment directly to Furnace Brook Physical Therapy for services rendered.

Signature of Patient/Parent/Legal Guardian * Date * Signature ________________________________
(You will be asked to sign this section of the form in person on your first visit) * = required information If this information is correct, please click "Submit" and the form will be sent to Furnace Brook Physical Therapy.

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