Intake Form

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Payson Physical Therapy                                    
405 W Main St, Suite D, Payson, 85541                
Name: ________________________________ Date of Birth: _____\_____\_________   
Address: _________________________________   Soc Sec #: _____________________
City: _____________________________________ State: _____ Zip: ________________
Home Phone: __________________ Work Phone: ________________    
Cell Phone: _____________________
Insured Person’s Name: ______________________________________   
Date of Birth: _____\_____\_________           
Employer: _____________________________________ Work related injury?     Y   N    
Referred By: ________________________________   Motor vehicle accident?     Y   N 
Primary Insurance: _________________________________________________________
Secondary Insurance:________________________________________________________
Chief complaint: _________________________________________________________________________
Date of Injury or Surgery: _____\_____\_________ 
How did injury occur? _______________________________________________________
History of:       
Y   N   Diabetes (type___ years___)               
 Y  N   Heart Disease/ Arrhythmia
Y   N   Pacemaker                                          
Y   N   Seizures
Y   N   Cancer (where___________)              
Y   N   Decreased Sensation (where ____________)
 Operations: _________________________________________________________________________
 Current medications: ________________________________________________________________________
 Allergies: _________________________________________________________________________
 By signing below,
1)      I consent to treatment at Payson Physical Therapy (or treatment of child if signing as parent/ guardian).
2)      I authorize Payson Physical Therapy to release medical information to my insurance and my physician.
3)      I authorize Payson Physical Therapy to bill and collect payments from my insurance company.
4)      I agree to accept financial responsibility for my treatment including co-pays and deductibles.
5)      I acknowledge receipt of the “Federal Notice of Information Policies”
6)      I acknowledge the health and personal information above is true to the best of my knowledge.
Signature: _______________________________________________________

Printed Name: ___________________________________________________
Date: _____\_____\_________ 
Please let us know if you have any questions or concerns regarding treatment, scheduling, or billing.