Lamorinda Orthopaedic & Sports PT

"Rehabilitation for the Orthopedic Patient"

AMORINDA ORTHOPAEDIC & SPORTS PHYSICAL THERAPY REGISTRATION FORM

DIRECTIONS: Please print, complete and bring to first appointment or email as an attachment to [email protected].

Today's Date: Referring Dr.

PATIENT INFORMATION

Patient's last name:

First:

Middle:

Is this your legal name? Y N

If not, what is your legal name?

Marital status: Single Mar Div Sep Wid

Birth date: Age: Sex: M F

Address:

Cell phone number:

Home phone number:

Email Address:

Occupation:

Employer:

Employer phone number:

Other family members seen here:

INSURANCE INFORMATION

Person responsible for bill:

Birth date:

Address (if different):

Contact phone no. area code first:

Is this person a patient here? Y N

Is this patient covered by insurance? Y N

Please indicate primary insurance:

Subscriber's name:

Subscriber's I.D. no.:

Birth date:

Group no.:

Policy no.:

Co-payment:

Patient's relationship to subscriber: Self Spouse Child Other

Name of secondary insurance (if applicable):

Subscriber's name:

Group no.:

Policy no.:

EMERGENCY CONTACT

Name:

Phone Number:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the therapist. I understand that I am financially responsible for any balance. I also authorize Lamorinda Physical Therapy or insurance company to release any information required to

process my claims.

Please sign and date at the time of initial visit.

Patient/Guardian signature:

Print Name:

Date: