NEW PATIENT FORM Fenton Physical Therapy new patient forms online. Patient Name(Required) First Middle Last Patient Date of Birth:(Required) MM slash DD slash YYYY Patient Social Security # : (last 4 digits only)(Required) Gender:(Required) Male Female Marital Status:(Required) Single Married Other Contact Information:Address (No PO BOXs) Street:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:(Required)Cell Phone:(Required)Email:(Required) Occupation:(Required) Employment Status:(Required) Full Time Part Time Retired Unemployed Student Employer:(Required) Provide your employer name or type NONE if you don't have an employer Emergency Contact Name:(Required) Relationship: Spouse Parent Other Best Phone Number:(Required)Family Doctor:(Required) Office Phone:(Required)How did you hear about our office?(Required) Reason for appointmentPlease describe the problem that brings you in today (be specific):(Required)Date of Injury: MM slash DD slash YYYY Have you had this problem before?:(Required) No Yes Have symptoms been getting...: Better Worse No Change What makes symptoms better?:(Required) What makes symptoms worse?: Rate current pain level(Required)0123456789100 is low to 10 highRate pain level at its worst(Required)01234567891001 is low to 10 highRate level at its best(Required)0123456789100 is low to 10 highHave you had surgery?(Required) No Yes If yes provide the surgery date.Surgery date MM slash DD slash YYYY If you had surgery relate to this injury select the date.Insurance CarrierPrimary Insurance Carrier:(Required) Name of Policy Holder:(Required) Policy Number:(Required) Policy Holder DOB:(Required) MM slash DD slash YYYY Second Insurance Carrier: Name of Policy Holder: Policy Number: Policy Holder DOB: MM slash DD slash YYYY Privacy Information:Name of person(s) who can access your records/PHI or pick up records.First & last name and relationship: First & last name and relationship: First & last name and relationship: AttestAccept terms(Required)I do hereby attest that this information is true, accurate and complete to the best of my knowledge. understand that any falsification, omission or concealment of any material fact may subject me to all fees for services and/or other liability. I also understand that I am to notify Fenton Physical Therapy immediately of any changes to the above information and annually upon the office’s request. I also acknowledge that I have been provided the opportunity to take and review the office’s HIPAA Policy, Authorization from Patient or Legal Representative, and Notification of Office Policies and Procedures (version 10-01-2021). (Available in our waiting room and/ or by request). I further acknowledge and accept all the terms and conditions outlined in all forms listed including “notifications of office policies and procedures”, “HIPAA policy notice of privacy practices”, and “authorization from patient or legal representative”. I authorize Fenton Physical Therapy to contact me via text and email. (MSG & date rates may apply) I Agree Attest to submission(Required) By typing in your full name in this field you are agreeing to the terms and conditions related to the online submission of your information.Terms of agreement date MM slash DD slash YYYY Date of the agreement to term of online submission of patient information.
