PT Form To save time and allow us to better serve you, please complete all questions below. Thank you! Patient First Name:* Patient Last Name:* Address:* City:* Age:* Birthday:* SSN: (optional) Gender:* MaleFemale Phone:* Email:* Emergency Contact First Name:* Last Name:* Relationship:* Phone Number:* Employer Name:* Phone Number:* Referring Physician:* Phone Number:* Have you been treated by PT, OT, ST, or by any other agency?* YesNo Workman's Comp?* YesNo Auto Accident?* YesNo If yes, date: Patient Medical History:* (Please write Y or N, or details where applicable) Heart Trouble (Heart Attack, Chest Pain) Pace Maker Neurological Conditions (Parkinsons, Stroke) Metal Implants (Pins, IUD, Screws, Plates) Allergies, Hay Fever, Medicine Respiratory Conditions (SOB, Asthma) Alcohol Abuse Gout Diabetes Numbness Major Accidents Cancer (if yes, list type/location) Hypertension Broken Bones Anemia Arthritis Seizures Currently Pregnant? Insurance Information Primary Insurance Insurance Company:* Policy Number: Group Number: Claim Number: Secondary Insurance Insurance Company: Policy Number: Group Number: Claim Number: Acceptance of Services and Financial Responsibility:* I have read and agree to the Acceptance of Service; Medical Information Authorization; Assignments of Benefits; and Financial Responsibility as outlined HERE. I agree. Appointment Reservation Policy:* I have read and agree to the Appointment Reservation Policy. I agree. Authorization:* I have read and agree to the conditions of Consent. I agree. Patient Bill of Rights:* I have read and agree to the Patient Bill of Rights. I agree.