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New Patient Form

Patient Name

DOB

If Minor, name of parent/guardian

Emergency Contact Name/ Relationship

Emergency Contact Phone Number

Phone

Address

Medical History

Heart Disease

Pacemaker

Seizures

Asthma

Medical History

Heart Disease

Pacemaker

Seizures

Asthma

Allergies

Latex

Lotions

Other

If Other

Primary Insurance

Primary Insured DOB

If so, what is the date of your accident?

Secondary Insurance

Secondary Insured DOB

Consent to Release Information: I authorize Excel Physical , Inc permission to discuss my account with the following individual.

Is this related to an auto accident?

Yes

The Health Insurance Portability and Accountability Act (HIPAA) provide safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003.

Assignment of Benefits: I assign all benefits to Excel Physical Therapy, Inc. I authorize release of records to any agency involved in the payment of treatment for the patient named below. I understand in the event that collection is necessary, I am responsible for all collection and attorney fees accrued on my account

No Show Cancellation Policy

There will be a $25 fee charged to your account for any no shows or for appointments not cancelled at least 24 hours prior to the appointment

Name of Patient or Parent/Guardian

Todays Date