Client Intake Form
Name: __________________________________________________ Date: ___________________
SSN:______________________________________________ Sex: Male Female
Parent / Guardian:________________________________ SSN:____________________________
Address: ________________________________________________________________________
City: _______________________________________________ State: _______ Zip: ____________
Daytime Phone #: _________________________ Evening Phone #: _________________________
Cell Phone #____________________________ Email Address:_____________________________
Date of Birth: ___________________________ Occupation: _______________________________
Employer: ________________________________________________________________________
Employer’s Address: _______________________________________________________________
Type and location of injury__________________________________ Marital status: Single Married
Referring Doctor: ________________________Phone:__________________Fax:_______________
Primary Health Care Provider: ________________________________________________________
Provider’s Address: ________________________________________________________________
City:____________________________________ State: _______ Zip: ____________
Telephone #: _____________________________________ Extension: ______________
Permission to Consult with Primary Provider? No Yes ____________(please initial if yes)
In Case of Emergency, Please Notify: Name: ____________________________________________
Telephone #: _______________________ Relationship: ___________________________________
Preferred Appointment Day and Time: ___________________
How did you hear about Omni Physical Therapy?
Physician
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By my signature below, I authorize OMNI PHYSICAL THERAPY LLC. to treat me. I understand I have the right to refuse this treatment. All
medical expenses shall be my responsibility. I agree to pay any additional charges related to the cost of collection (including but not limited to
finance charges, interest, collection agency fees, reasonable attorney’s fees and court costs). I authorize ASAPC to release any medical
information necessary for the processing and payment of my bills to any insurance company or other third-party payer who is or may be
responsible for paying for medical treatment. I further authorize release of copies to the referring physician or physicians consulted in regard to
said treatment. I further authorize the use of said records for the purpose of Workmen’s Compensation disclosure. I hereby assign, transfer,
and set over to Omni Physical Therapy LLC all of my rights, title and interest to my medical reimbursement benefit under my insurance
policy.
SIGNATURE : _________________________ Witness _______________________ Date_________
Patient or parent/guardian of minor child
