PATIENT INFORMATION

First Name:   Middle Initial:
Last Name:    Male Female

Street Address:   Apt. #:
City:   State:   Zip Code:

Home Phone: () -
Work Phone: ()-
Cell Phone: ()-

Date of Birth (mm/dd/yyyy): / /   Age:

Social Security #:
Driver's License (please provide a copy for our files): Number   State

Employer:   Occupation:

Employer Address:   City:
State:   Zip Code:

Marital Status: Single   Married   Divorced   Widowed   Separated

Date of Current Injury (mm/dd/yyyy):

Emergency Contact:

First Name:   Last Name:
Relationship to Patient:

Home Phone: ()-  Cell Phone: () -

Person Responsible for Charges (if patient is under 18 years of age):
Relationship to Patient:

Address (If Different from Above):
Street Address:   Apt. #:
City:   State:   Zip Code:

PHYSICIAN INFORMATION

Referring Physician:
First Name:   Last Name:
Office Phone: () -

Office Address:
Street Address:   Suite #:
City:   State:   Zip Code:

INSURANCE INFORMATION
Primary Insurance (Please provide card)

Name of Policy Holder:
Date of Birth (mm/dd/yyyy): / /
Social Security Number:

Address of Policy Holder (If Different from Above):
Street Address:   City:
State:   Zip Code:

Insurance Co:   Phone #: () -

Subscriber #:   Group #:
Relationship to Patient:

Policy Holder's Employer (If Different from Above):
Name:   Address:
City:   State:   Zip Code:

Secondary Insurance (If applicable, please provide card)

Name of Policy Holder:
Date of Birth (mm/dd/yyyy): / /
Social Security Number:

Address of Policy Holder (If Different from Above):
Street Address:   City:
State:   Zip Code:

Insurance Co:   Phone #: () -

Subscriber #:   Group #:
Relationship to Patient:

Policy Holder's Employer (If Different from Above):
Name:   Address:
City:   State:   Zip Code:

Authorization for Treatment

I hereby consent to and authorize all therapy treatments, which in conjunction with the judgments of the attending physician may be considered necessary or advisable for the diagnosis or treatment of the patient named above, at Rancho Physical Therapy.

Please remember to sign your printout.