Patient Intake Form

Please fill out this form completely so we can provide you with the best possible care.

Referral Information

Referring Physician/Agency

Date of Referral

Patient Information

First Name*

Last Name*

Address*

City*

State*

ZIP Code*

Phone Number*

Email Address*

Date of Birth*

Insurance Information

Insurance Provider*

Policy Number*

Medicare ID

Emergency Contact

Full Name*

Relationship*

Phone Number*

Medical and Surgical History

Please check all that apply and provide a brief description.

Diabetes

Hypertension

Arthritis

Osteoporosis

Cardiac Conditions

History of Stroke/TIA

History of Falls

Recent Surgery

Other Medical Conditions or Surgical History

Current Symptoms

Reason for Therapy*

Please describe your pain/symptoms (e.g., location, type, severity)

Cancellation and No-Show Policy

To ensure we can provide timely care to all of our patients, we require a minimum of 24 hours' notice for any appointment cancellations or rescheduling. We understand that unexpected events can occur, so as a courtesy, we offer **one (1) free late cancellation or no-show** per patient. After this first instance, our standard cancellation policy will apply.

Late Cancellation (less than 24 hours' notice): A fee of $60 will be charged.
No-Show (failure to attend without any notice): A fee of $90 will be charged.

This fee is your personal financial responsibility and will not be billed to Medicare or any other insurance provider.

I have read and agree to the Cancellation and No-Show Policy. *

Consent and Acknowledgment

I authorize Tobias Therapy to provide physical therapy services as deemed necessary and to release any information required to process my claims with Medicare or other insurance providers. I acknowledge that I have been informed of the potential risks and benefits of physical therapy. By submitting this form, I confirm that I have been given the opportunity to review the HIPAA Notice of Privacy Practices. *

Signature

By typing your name below, you agree that the information provided is accurate to the best of your knowledge.

Full Name*