Patient Form

REGISTRATION FORM

PATIENT DEMOGRAPHIC INFORMATION

EMPLOYER INFORMATION

EMERGENCY CONTACT INFORMATION

PRIMARY INSURANCE SECTION

SECONDARY INSURANCE SECTION

PERSONAL HEALTH HISTORY

This form will be a part of your medical record. Upon completion, please sign the last page.

Past Medical History

I certify that the above information is correct to the best of my knowledge. I will not hold my therapist or any members of the office staff responsible for errors or omissions that I may have made in completing this form.

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that the information can and will be used to:

• Conduct, plan and direct my treatment and follow-up amoung the
  multiple healthcare providers who may be involved in that treatment directly and indirectly
• Obtain payment for third-party payers
• Conduct normal healthcare operations, such as quality assessment and physician's certifications

I have reviewed/read the office's Notice of Privacy Practices posted in the lobby. I understand your Notice of Privacy Practices contains a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practice from time to time and that I may contact this organization at any time to obtain a current copy of its Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operation. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

CANCELLATION / NO SHOW / LATE FEE

We understand that you may sometimes need to reschedule appointments. When we make your appointment, please understand we are reserving time for you to see a therapist. This courtesy makes it possible to give the best services here at Revolve PT. If you need to reschedule an appointment, please call the clinic as soon as possible or call at least 24 hours in advance. I consent to rehabilitation and related services at: REVOLVE PHYSICAL THERAPY. In doing so, I understand, acknowlege and affirm that such rehabilitation and related services may involve bodily contact, touch and/or direct contact of a sensitive nature.

• If canceling the same day as your session or simply no-show, you will be responsible for a $50 out-of-pocket cancellation fee.
• If arriving more than 15 minutes late a $30 fee will be applied to your visit.

We thank you for your trust in us here at Revolve Physical Therapy.

Disclosure of Medical Records

I authorize the following individuals to have access to my medical and billing records:

I certify that all of the information provided herein is true and correct.

Dry Needling (DN)

DN is a technique that involves the insertion of acupuncture needling in the soft tissues of the musculoskeletal system as a means to promote healing within the body. Treatment techniques are based on concepts of motion medicine and should not be considered acupuncture. Risk of injury is real and potential complications could result from DN if proper precautions are not observed. Pneumothorax could result from insertion of a needle into lung tissue; if DN is practiced properly, threat of pneumothorax is extremely low.

Other complications that could result from DN:

• Bleeding, bruising, infection or nerve injury

DURING a DN treatment you may experience temporary:

• Pain, sweating, nausea, anxiety, dizziness, pain referral or muscle twitch

AFTER a DN treatment you may experience temporary:

• Muscle soreness, muscle tightness, paresthesias or joint stiffness

Contraindications to DN:

• Vascular Disease
• Bleeding or Clotting Disorder
• Taking Blood Thinners
• Diabetics with significant sensory and/or circulation disorders
• Pregnancy
• Skin Cancer (over affected area)

I have read the above, I understand the risks involved with dry needling and cupping. I have had the opportunity to ask any questions I had and all my questions have been answered. I consent to treatment at Revolve Physical Therapy.

CONSENT TO TREATMENT

I consent to rehabilitation and related services at: REVOLVE PHYSICAL THERAPY. In doing so, I understand, acknowlege and affirm that such rehabilitation and related services may involve bodily contact, touch and/or direct contact of a sensitive nature.

TREATMENT OF MINORS

I, as a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resukting from failure to do so.

LIABILITY

I know and agree that REVOLVE PHYSICAL THERAPY is not responsible for loss or damage to personal valuables.

WAIVER AND RELEASE

I hereby release, discharge and acquit: REVOLVE PHYSICAL THERAPY its agents, representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive, or allow emergency and or medical services including but not limited to ambulance service, Emergency Medical Technician, physician urgent care or services.

AUTHORIZATION OF PAYMENT

I hereby assign all benefits directly to: RESOLVE PHYSICAL THERAPY. I also authorize release of any medical records to other healthcare providers as necessary to facilitate my treatment and to other third parties as necessary to process medical claims and otherwise premitted or required in the Notice Of Privacy Practices.

FINANCIAL POLICY

I understand fully that, in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment. To assist in establishing your account, please:

• Supply all necessary informatoin for accurate billing of your claim, including your insurance card, drvier's license, employer information, and demographic information.
• Satisfy all insurance co-payments, co-insurance, deductibles, and non-covered services on the day services are rendered.
• Provide your insurance company and us with any additional information requested to complete the processing of claims filed on your behalf.