Your Email Address(Required) This individualized plan is created with input from you, your therapist, and your doctor to help the patient achieve their goals as quickly as possible. Moving forward in filling the form may take 15-20 minutes.
Whom may we thank for referring you?*(Required) Doctor Family Member Friend Website Other
You may choose more than one by using CTRL button and selecting more than one.
Patient Information Now we will begin asking Patient Personal Information. This is just the patient name, age, and additional details
Your Name(Required)
First
Last
Sex(Required) Patient Address
Now We Are Going To ask Some Questions For Emergency Contact In case of Emergency whom we should contact
Emergency Contact Name(Required)
First
Last
Acknowledgement- I understand and agree to the terms outlined in this acknowledgement and hereby give my signature as confirmation of my understanding and acceptance.(Required) I confirm that the information provided is accurate to the best of my knowledge. By signing, I give my consent for physical therapy treatment and authorize Atala Physical Therapy to bill my insurance directly for payment. I understand that any charges not covered by insurance are my responsibility. Additionally, I authorize the release of any necessary information to process my claims and secure benefits.
Signature I authorize the release of any necessary information to process my claims and secure benefits.
Now We Are Going To ask Some Questions For Your Physical Therapy Evaluation To help us assess the cause of your problem, we ask you to complete this form before being seen by a physical therapist. Please answer as completely as possible.
Your Full Name(Required)
First
Last
Are you currently working?(Required) Yes, I am Working No, I am Not Working
Have you fallen in the last six months?(Required) Yes, I I have Fallen No, I have Fallen
Please explain in more details about your fall or falls
What happened to cause the fall, what hurts because of it and is this the result of something else?
What Physical Activities/Sports Do you participate on a regular basis?(Required)
Any type of activities and or sports you do on a regular basis
Now We Are Going To ask Some Questions about complaints and pains To help us assess the cause of your problem, we ask you to complete this form before being seen by a physical therapist. Please answer as completely as possible.
Are there any positions or activities that make your pain worse
Please list anything you can think of that causes the pain to be worse
Are there any positions or activities that lessen the pain?(Required)
Please list anything that helps lessen the pain from positions to ice, to stretches.
Now We Are Going To ask Some Questions about The History Of your injury To help us assess the cause of your problem, Please fill out as much information as you can about what, how, why this started and the medical history to make sure we understand.
How did this problem or pain start?(Required)
This could be what you were doing, what happened as a result or anything that might give us an idea of what caused this.
Did you have any surgeries before? Yes, I have Had Surgery or surgeries. No, I have not had surgery I am going to have surgery
Please List surgeries and Dates
Please give us as much information as possible and close dates of when you have had surgery and what it was for.
Do you have any previous or current health conditions? (diseases, infections, etc)(Required) Yes No Not Sure
Please list both previous and current diseases, but not limited to, heart disease, lung disease, diabetes, stroke
Have you recently had an x-ray/MRI? No Yes
In the past year have you had a MRI or Xray
Which word best describes the quality of your discomfort?(Required) Burning Sharp Dull/Achy Shooting Numbness/Tingling Constant Intermittent
You Can Choose more than one.
Now We Are Going To ask Some Questions about Medication History Due to insurance regulations, we must keep a record of any medications you are taking. Please take the time to all out your medications, dosages and the reason for taking medications.
Do you have any Medication History?(Required) Notice of Patient Information Practices This notice describes how medical information about you may be used or disclosed and how you can get access to information. Please review carefully.
Signature of patient or legal guardian(Required) I hereby consent to using and disclosing my personal health information for purposes as noted in the Atala Physical Therapy’s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice at any time.
Deductibles and Co-Pays(Required) All patient responsibility deductibles and co-pays are due in full at the time of service. A receipt will be provided for any charges processed by Atala Physical Therapy, if requested. I have read the above and I agree to the terms and conditions. I hereby consent to medical care and treatment as deemed necessary and proper by the medical staff of Atala Physical Therapy. I agree to assign all health insurance benefts directly to Atala Physical Therapy and understand that I am responsible for any costs not covered by or denied by my health insurance.
Signature of patient or legal guardian(Required) I hereby consent to using and disclosing my personal health information for purposes as noted in the Atala Physical Therapy’s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice at any time.
**Our official corporate name is Atala Physical Therapy, Inc.
Thus, this official name may appear on your billing/credit card statement.**
Patient Treatment Agreement(Required) Cancellation Policy. I understand that if I cancel my scheduled appointment with less than 24 hours notice, or fail to show up for a scheduled appointment, a $50 cancellation fee will be assessed to me. I understand that if I fail to show up for a scheduled appointment without a call, a $75 no-show fee will be assessed to me.
Patient Treatment Agreement(Required) I understand that Atala Physical Therapy is not responsible for any loss, theft or damage to my personal belongings, including my vehicle. I agree not to hold Atala Physical Therapy liable for any such incidents and release them from any potential claims in relation to my treatment at their facility.
Patient Treatment Agreement(Required) I understand that it is my responsibility to verify my Physical Therapy Benefits with my health plan, including but not limited to, deductibles, co-pays, number of visits allowed, and any prescription or pre-authorization requirements. I agree that I am financially responsible for any treatment provided to me in the event that my insurance carrier does not cover the full cost of my treatment. I will be given a copy of my insurance verification form, which will detail the benefits that Atala Physical Therapy confirmed for me on the date of my evaluation.
Patient Treatment Agreement(Required) I represent that I am physically able to safely participate in physical therapy and I have received clearance from my physician to undergo physical therapy.
Do you agree of being photographed or videotaped while receiving physical therapy for purposes of advertising and/or social media? As a new patient of Atala Physical Therapy, I hereby acknowledge and understand the following. Physical therapy means the art and science of physical or corrective rehabilitation or physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise, and shall include physical therapy evaluation, treatment planning, instruction and consultative services (collectively “Therapy”).
The practice of physical therapy includes the promotion and maintenance of physical fitness to enhance the bodily movement related to the health and wellness of individuals through the use of physical therapy interventions. Physical therapists are not authorized in California to diagnose disease(s).
Atala Physical Therapy does not discriminate, and therapy being provided by Atala Physical Therapy is provided without regard to the patient’s race, religion, gender, color, national origin, ancestry, physical handicap, medical condition, marital status, age, or sex. Response to therapy treatment varies by individual. Therefore, it cannot and Atala Physical Therapy has not, predicted my response to therapy.
While the goal is for improvement of the condition in which I am seeking therapy, I understand that there is a possibility that my condition may worsen and therapy may cause pain, injury and even death. I also understand and acknowledge that I may develop new or different injuries as a result of my participation in a physical therapy program and in receiving therapy.
With full knowledge of the above, I hereby knowingly and voluntarily assume any risks associated with the therapy that I receive, and I, along with my heirs and assigns, fully and forever release Atala Physical Therapy, its owners, partners and providers of therapy services from any and all injury which may naturally occur and which are inherent in receiving therapy.
Check to Consent(Required) I understand that it is important to inform my physical therapist of any medical conditions that may affect my therapy. If I am unsure if a condition will affect my therapy, I will discuss it with my therapist before starting treatment.
Check To Consent(Required) I understand that it is my right to decline to participate in physical therapy in general and specifically in any treatment proposed by Atala Physical Therapy. I will immediately notify my physical therapist of any pain, discomfort, dizziness, or other concerns. I understand that it is my right to ask the physical therapist about my specific treatment plan and the associated risks and benefits. I further acknowledge that I have consulted with my physician before participating in therapy to determine whether therapy is safe, warranted, and recommended. I have been informed that it is.
Check To Consent(Required) I have read, acknowledged, adopted, understood, and have agreed to be bound by the previous consents
