Online Patient Form

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First Visit ExpectationWhat To Expect At Your First Visit

Atala Physical Therapy will redefine your patient care experience.
We aim to excel in service and experience. We strive to exceed your expectations!

What to Wear on Your First Visit?

Please wear comfortable and athletic clothing. Closed toe shoes, preferably tennis shoe/sneaker. Please
arrive 15 minutes early to your scheduled appointment to complete all required paperwork and answer any
questions you may have.

What Should I Bring?

• Completed paperwork
• Insurance card
• Physician’s prescription for physical therapy, if you have one
• Medication List
• Recent imaging (X-Ray, MRI), if you have any

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.
Please call us with any questions or concerns you may have
Moving forward in filling the form may take 15-20 minutes

ReferrerPlease provide accurate information

Date *

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Name of Referring Party*

Please specify referrer

Patient InformationPlease provide patient personal information

Enter First Name

Enter Last Name

Age*

Age

Sex*

Male

Female

Cell Phone Number

Home Phone Number

Address *

Street Address

City

Zip Code

Email Address

Occupation*

Occupation

Employer

Employer Phone Number

Doctor's InformationProvide your referring physician details

Referring Physician/Family Doctor*

Referring Physician/Family Doctor

Phone Number

Emergency ContactIn case of Emergency whom we should contact

Name

Relationship to Patient*

Relationship to Patient

Home Phone Number

Cell or Work Phone Number

AcknowledgementI understand and agree to the terms outlined in this acknowledgement and hereby give my signature as confirmation of my understanding and acceptance.

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*

Enter your initials to sign

Initials

Medication HistoryProvide any medication history you may have

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?*

Yes

Medication

Dosage

Reason

Medication

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Reason

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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.

Atala Physical Therapy’s Legal Duty

Atala Physical Therapy is required by law to protect the privacy of your personal health information, provide this notice about our information practices, and follow the information practices that are described. herein.

Uses and Disclosures of Health Information

Atala Physical Therapy uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities; and evaluating the quality of care we provide. For example, we may use your personal health information to contact you to provide appointment reminders, information about treatment alternatives, or other health-related benefits that could be of interest to you.

Atala Physical Therapy may also use or disclose your health information, without prior authorization, for emergencies and auditing purposes. We also provide information when required by law. In any other situation, our policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Atala Physical Therapy may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and patient exam area and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time.

Patient’s Individual Rights

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment, or other related administrative purposes. You may request in writing that we not use or disclose your personal health information for treatment, payment, and administrative purposes except when specifically authorized by you when required by law or in emergency circumstances. Atala Physical Therapy will consider all such requests on a case-by-case basis, but the practice is not legally required to accept them.

Concerns and Complaints

If you are concerned that we may have violated your privacy rights or disagree with any decisions we have made regarding access or disclosure of your personal health information, don’t hesitate to contact our Privacy officer at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on our health information practices or if you have a complaint, please contact:

Terri Brusseau Kraus, Owner (760) 727-9100
Atala Physical Therapy, Grey Hawk Business Center, 3222 Grey Hawk Court, Carlsbad CA 92010

Atala Physical Therapy’s Legal Duty

I have read and fully understand Atala Physical Therapy’s Notice of Information Practices. I understand that Atala Physical Therapy may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of service provided, and any administrative operations related to treatment or payment.

I understand that I have the right to restrict how my personal information is used and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand that Atala Physical Therapy will consider requests for restriction on a case-by-case basis but does not have to agree to requests for restrictions.

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.

Name

Signature *

Enter initials to sign

Patient Signature

Date*

Select Date ×

Parent/Guardian Signature

Enter initial to sign

Parent/Guardian Signature

Payment AuthorizationsAuthorize any Deductibles and Co-Pays

Deductibles and Co-Pays

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.

Patient Signature*

Enter initials to sign

Patient Signature

Date *

Select Date ×

**Our official corporate name is Atala Physical Therapy, Inc.
Thus, this official name may appear on your billing/credit card statement.**

Patient Treatment AgreementTerms for treatments

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.

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.

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.

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?*

Yes

I agree that I have read, understand and agree to the terms listed above and that I have been advised to seek legal counsel in the event that I do not understand any of the above.

Printed Name

Date*

Select Date ×

Signature*

Enter initials to sign

Signature

Consent AgreementInformed Consent Agreement

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.

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.

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.

I have read, acknowledged, adopted, understood, and have agreed to be bound by the above

Printed Name

Date*

Select Date ×

Signature*

Signature

PARENT or LEGAL GUARDIAN

Printed Name

Date*

Select Date ×

Signature*

Signature

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First Visit ExpectationWhat To Expect At Your First Visit

What to Wear on Your First Visit?

What Should I Bring?

ReferrerPlease provide accurate information

Patient InformationPlease provide patient personal information

Doctor's InformationProvide your referring physician details

Emergency ContactIn case of Emergency whom we should contact

AcknowledgementI understand and agree to the terms outlined in this acknowledgement and hereby give my signature as confirmation of my understanding and acceptance.

Physical Therapy EvaluationTo be completed by patient

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.

Complaint

History

Areas of Concern

1

10

1

10

1

10

Medication HistoryProvide any medication history you may have

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.

Notice of Patient Information Practices

Atala Physical Therapy’s Legal Duty

Uses and Disclosures of Health Information

Patient’s Individual Rights

Concerns and Complaints

Atala Physical Therapy’s Legal Duty

Payment AuthorizationsAuthorize any Deductibles and Co-Pays

Deductibles and Co-Pays

Patient Treatment AgreementTerms for treatments

Consent AgreementInformed Consent Agreement

As a new patient of Atala Physical Therapy, I hereby acknowledge and understand the following.

PARENT or LEGAL GUARDIAN

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