ABC PT Physical Therapy New Patient Information Sheet

Directions: Print out New Patient Information Sheet, fill it out, and bring it with you to your first appointment or mail it to
3502 S. 12th Street, Suite B, Tacoma, Washington

Date ______ Referred by Doctor: ____________Yellow Pages:_____ Friend: ___________ Other: _________

Patient Information

Name of Patient: __________________________________________________ Marital Status: S M D W

Address: _____________________________________________________________________How long? __________

City: ___________________________________________________ State: ______________ Zip: ________________

Home Telephone: _______________________________ Work Telephone: __________________________________

Patient’s Date Of Birth: _______________Patient’s Sex: M/ F Patient’s Social Security #___________________

Employer: ___________________________How Long? _____ Occupation __________________________________

If Married, Spouse’s Name: _________________________ Spouse’s Social Security #__________________________

Spouse’s Employer: _____________________ Occupation: _________________ Work Telephone: _______________

List any medications you are currently taking: _________________________________________________________

Primary Insurance Secondary Insurance

Name of Insured:	Relationship to Patient:		Name of Insured:	Relationship to Patient:
Birth Date:	Employer:		Birth Date:	Employer:
Insurance Company/ Auto Carrier:			Insurance Company/ Auto Carrier:
ID Number:		Group Number	ID Number:		Group Number
Insurance Claims Adjuster/ Phone Number			Insurance Claims Adjuster/ Phone Number

Person To Call In Case Of Emergency

Name:

Address:

Phone:

Relationship

Although services may be covered by insurance, I understand I am fully responsible for payment for care I receive. I understand an administrative service charge of 1% compounded or $1.50 per month, whichever is greater, will be charged on all unpaid balances. I authorize payment of medical benefits to my physician for services rendered. I authorize the doctor or insurance to release any information required for services rendered by this office. I give ABC PT permission to use a collection service, if by chance my account is 90 days over do.

Signed: _______________________________________ Dated: __________________