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Patient Intake Information Wizard
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Patient Information
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Consent Form
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Patient form for Medical Record
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Patient Information
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Patient Problem History
When did this problem begin?
How did this problem begin?
Date of Surgery: (if applicable)
Symptoms/Pain: (check all that apply)
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Rate Symptoms on a scale:
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Are your symptoms:
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Do you use any of the following:
Neck/Back cushion
Back Brace
Splints
Orthotics
Have you recently had:
Unexplained weight gain/loss
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Have you had any medical tests or diagnostic imaging for this problem? Check all that apply
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Have you received any treatment for this problem? If so, please describe:
Are you currently taking any over the counter medications?
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Medical History: Please Check all that apply
High/Low Blood Pressure
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Have you been in contact with anyone COVID-19 positive in the past 14 days?
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Have you experienced fever, cough, or shortness of breath in the past 14 days?
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Consent Form
Patient No-Show/Cancellation Policy:
At Pro-Active Physical Therapy, we strive for a fair policy regarding cancellations and no-show’s. Physical Therapy is an on-going process that requires both regular attendance, as well Punctualness both from the patient and provider.
At Pro-Active Physical Therapy, a "patient no-show" is defined as a patient not arriving for a scheduled appointment "on-time"
.
Patient Tardiness Policy:
Please be on-time to your appointment, as it encourages effectiveness in your treatments and maximizes your time with your provider.
Patients who arrive 10 minutes past their scheduled appointments will be seen for the time allowed to their care
.
Cancellation/Rescheduling Appointment Policy:
We understand that our patients have commitments and life events outside of their control.
We ask that you provide the office
24 hours notice
on the previous business day before both canceling OR rescheduling appointments
. This means that Monday appointments MUST be canceled or rescheduled by the previous Friday by noon time. We ask that you call our Office at 408-720-1700 to make these desired changes.
Failure to Comply:
Patient failure to comply with patient no-show policy, patient tardiness or patient cancellation/rescheduling policy will be subject to a $75.00 cancellation fee.
This fee is the patient's personal responsibility.
Financial and Agreement to pay Policy
It is your responsibility to know your insurance coverage and Physical Therapy benefits, especially pre-certification requirements and/or limitations. We will submit claims on your behalf, provided you provide accurate billing information. If your insurance company fails to pay the claims, then you are responsible for paying the outstanding balance once we have received notification from your insurance company.
Your credit card information will be required at the time of check-in.
. I understand and agree that I am financially responsible and liable for payment of charges assessed to me for professional services rendered by PAPT. You are required to send payment immediately to PAPT in the case that the Insurance company forwards payment services to you. You also accept responsibility for charges for returned checks and fee for collection action, if necessary.
Privacy Policy
PAPT’S Notice of Information Practices posted. I have read and understand that PAPT may use and disclose my personal health information for purposes of providing treatments, obtaining payment and evaluating the quality of services provided and administrative functions related to treatments or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative functions by notifying PAPT. I understand that PAPT does not have to agree to my request for restrictions. I consent to use and disclose my personal health information for the purpose noted above. I can revoke this consent by notifying PAPT in writing at any time.
I have read and agree to all the terms, conditions and
policies
.
