Self Pay Information Form

SELF PAY PATIENT INFORMATION SHEET DATE:

PATIENT #: PLEASE ANSWER COMPLETELY, PLEASE PRINT LEGIBLY

Patient Name: ________________________________ Date of Birth _____________________Age__________ Address:

________________________________________________________________________ Gender:

City:

State

M¨ F¨

Zip Code:_______________________

Home Phone ____________________ Work Phone ____________________ Email __________________________________

Who can we thank for referring you to our practice? ¨ Internet? ¨ US WEST Yellow Pages ¨ Friend ___________________ ¨ Doctor_____________________________________________________ ¨ Other______________________________________

Date of Onset of Problem or Accident__________________________ Diagnosis/Symptoms:______________________________________________________________________________________ Are you consulting an attorney regarding this injury? o No o Yes Name:__________________ Phone:____________________ Was this injury a result of a motor vehicle or work accident? o No o Yes (please inform us of the details)

REQUEST AND CONSENT FOR PHYSICAL THERAPY TREATMENT I am hereby consenting to and requesting physical therapy services from PERFORMAX physical therapy to be provided by licensed physical therapists, therapist’s designees or assistants. My evaluation and treatment may include but not be limited to the following; observation and palpation, joint mobilization, soft tissue massage, exercise (land and/or aquatic), education and instruction, modalities such as ultrasound, and electrical stimulation and neuromuscular techniques. Additional Expenses: I understand that pillows, gym balls, electrodes and other supplies are an additional cost that is separate from the cost of physical therapy treatment. Further, if I receive Iontophoresis as a treatment for my ailment, I understand that this procedure requires special electrodes, medication, and a Medical Doctor’s prescription and is an additional charge beyond the cost of other physical therapy treatment. I understand that no guarantees have been or can be provided regarding the success of physical therapy. I have elected to self-pay for physical therapy services. I understand that payment in full is due at the time of service. I also understand that PERFORMAX will not bill my insurance, and this general consent for physical therapy treatment does not assign my benefits under any Medicare, Workers Compensation, Auto, or Group Health Policy. ____________________________________________________________________________ Authorized Signature

_________________________________________ Date

Please complete patient history questionnaire Performax Physical Therapy