Patient Intake Form – English

Last Name* Birth Date*
First Name* Age*
Middle Initial: Gender* MaleFemale
Other Phone/ Contact Name* Address*
Main Phone* City*
Email* State*
Zip Code*
Referred to Clinic by* Physician*
Physician Phone* Medical Conditions/ Surgeries*
Medications, Dosage & Frequency*

COVERAGE INFORMATION

Primary Insurance* Subscriber’s Name*
Policy* DOB*
Group* Relationship*
Secondary Insurance* Subscriber’s Name*
Policy* DOB*
Group* Relationship*
Is this a Motor Vehicle Accident?* YesNo Claim:
Is this a worker’s Compensation injury?* YesNo

Payment Policy:

1. All co-payments are due on the day of service.
2. All other payments (co-insurance, deductibles or other charges) are due immediately upon request from Ideal Therapy

Cancellation Policy:

Cancellations that are less than a 24-hour notice will result in $30.00 fee or possible termination from services.

Authorizations and Release of Information

I authorize Ideal Therapy to release medical documentation/ information to my insurance company, hospital, physician, attorney and any other medical institution that I am affiliated with.

I acknowledge that no guarantees, either expressed or implied have been made to me regarding the outcome of any treatments and or procedures. I understand that I have the right to consent or refuse any procedure or therapeutic course of treatment.

I agree to be personally responsible for all charge to my account; and I understand that all payments are due immediately upon request.

Assignment of Benefits

I assign Ideal Therapy to be paid by my insurance company for services rendered.
I DO NOT assign benefit to Ideal Therapy at this time. I am aware that I may do so later; and that if I proceed with treatment, all charges for care will be my sole responsibility.

Consent to Treat

I authorize Ideal therapy and its staff to perform care for as I am the legal guardian and or have current custody of this minor. Relationship:

Signature