Sending Patient Intake Form

Personal Information

Emergency Contact

Appointment Reminder Preference

Referral Information

During this calendar year, have you had any of the following Rehabilitation Services?

Insurance Information

Personal health history
General current conditions

Please read all and check all that apply to you


Diagnosed Condition

Specific Body Pain

Specific Current Conditions

0 Feel Great
1 - 2 Annnoying
3 - 4 Nagging Pain
5 - 6 Hurts even more
7 - 8 Intense Horrible
9 - 10 Unbearable

Pain Drawing


It is our goal to provide our patients with the highest quality of care while also attempting to accommodate our patients’ schedules for their convenience. Therefore, we provide reserved time slots for each patient in order to minimize our patients’ waiting time and assure continuity of treatment. Your consistent attendance of the planned treatment regimen is an important factor in your recovery.

While we are sensitive to the fact that emergencies may occur in rare instances, cancellations [especially those which are last minute] and missed appointments decrease our ability to accommodate the scheduling needs of other patients. Therefore, we require that our patients comply with the Cancellation and Missed Appointment Policy:

If you cancel a scheduled appointment less than twenty-four (24) hours prior to the scheduled appointment time, or if you do not arrive to the appointment at all, it will be considered a “missed appointment” and you will be charged a Missed Appointment Fee of $50.00;

I hereby request and consent to the performance of various modes of physical therapy on me (or the patient named below, for who I am legally responsible) by Focus Physical Therapy and/or other licensed physical therapists working at the clinic. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatments. I intend this consent form to cover the entire course of treatment of my present condition and for any future condition(s) for which I seek treatment. I understand that I may refuse treatment at any time and that I am responsible for my healthcare choices.

The office of Focus Physical Therapy is committed to upholding the security and confidentiality of personal information that you provide to us. We take responsibility of safeguarding your information very seriously. We do not share or sell patient information with anyone outside our office without your written consent. This policy covers information including personal, financial, or health information about a consumer or customer relationship.

I have been given a copy of the privacy policy of Focus Physical Therapy. I hereby authorize that my records of evaluation and treatment with the office of Focus Physical Therapy may be forwarded to referring physicians, specialists, or therapists, who are also involved in my healthcare. Your insurance claims will be transmitted through an electronic clearing house, in accordance with HIPPA regulations.

By agreeing below, I have read, or have had read to me, the above consent to evaluation and treatment statement, that I am aware of the privacy policy, and that I certify that my medical information above is correct to the best of my knowledge.

Co-pay/Co-Insurance and Deductibles not met are due at time service is rendered. If you cannot settle your account at the time of each visit, special arrangements must be made in advance with our office.

I would like to keep a credit card on file, to be charged weekly, for any-co-pays or coinsurance owed by me. (We accept Visa, MasterCard or Debit Cards).

Please see Insurance Verification/Financial Agreement for your Benefit Details.