Lamorinda Orthopaedic & Sports PT
Lamorinda Orthopaedic & Sports PT
"Rehabilitation for the Orthopedic Patient"
LAMORINDA ORTHOPAEDIC & SPORTS PHYSICAL THERAPY REGISTRATION FORM
LAMORINDA ORTHOPAEDIC & SPORTS PHYSICAL THERAPY REGISTRATION FORM
DIRECTIONS: Please print, complete and bring to first appointment or email as an attachment to sjm.dpt@gmail.com.
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: