Patient Intake Form - Rise and Recover Therapy Clinic

Patient Intake Form

Rise and Recover Therapy Clinic

6537 Preston Rd Suite B-1, Plano, TX 75024

Phone: (972) 565-3585 | Email: randrtherapyclinics@gmail.com | Fax: (972) 433 � 6620

To provide you with the best possible care, please take a few moments to complete your intake information. This helps us understand your needs better before your visit. Your privacy is our priority." to this one: "To ensure you receive the highest quality care, please take a few moments to complete your intake information. This allows us to better understand your needs ahead of your visit. Your privacy is always our top priority.

Patient Information

First Name *

Last Name *

Middle Initial

Date of Birth *

Social Security Number

Gender *

Male Female Non-binary Prefer not to say

Medical Diagnosis (ICD-10 Code & Description)

Address and Contact Details

Street Address *

City *

State *

Zip Code *

Home Phone

Mobile Phone *

Email Address *

Occupation and Demographics

Occupation

Employer

Marital Status

Single Married Divorced Widowed Separated

Ethnicity

Hispanic or Latino Not Hispanic or Latino

Race (Select all that apply)

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other

Emergency Contact

Full Name *

Relationship to Patient *

Phone Number *

Email Address

Does this emergency contact hold Medical Power of Attorney (POA) for you?

Yes No

If yes, please be prepared to provide documentation.

Medical Provider Details

Primary Care Provider (PCP) Name

PCP Phone Number

PCP Clinic Address

Referring Provider (if any)

Referring Provider Specialty

Insurance Details

Primary Insurance Company Name

Policy Number

Group Number

Policy Holder/Subscriber Name (if different from patient)

Subscriber Date of Birth

Subscriber Relationship to Patient

Upload Front of Primary Insurance Card

Upload Back of Primary Insurance Card

Please ensure images are clear. For your security, avoid uploading sensitive information if possible.

Do you have secondary insurance?

Yes No

Secondary Insurance Company Name

Policy Number

Group Number

Is your condition related to a work injury?

Yes No

Date of Injury

Worker's Comp Carrier

Claim Number

Patient Medical History

What is your primary reason for seeking therapy today? *

When did your symptoms begin? (Date or approximate time)

Please mark on the silhouette below where you are experiencing pain, numbness, or other symptoms.

On a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable, what is your current pain level?

Do you use any assistive devices?

Cane Walker Crutches Wheelchair Other (specify)

Do you use any braces/supports?

Back Brace Knee Brace Ankle Brace Wrist Brace Other (specify)

Current Level of Function

How does your condition affect your self-care activities (e.g., dressing, bathing, eating)?

How does your condition affect your ability to perform household duties (e.g., cleaning, cooking, laundry)?

How does your condition affect your hobbies/recreational activities?

Describe your typical exercise history/routine prior to your symptoms:

History of Falls:

Yes No

History of Broken Bones:

Yes No

Family Medical History

Please list any significant conditions, e.g., heart disease, diabetes, cancer:

History of Swelling:

Yes No

For Lymphedema Therapy Only

History of Cancer?

Yes No

What type(s) of cancer?

Present status of cancer (e.g., in remission, active, post-treatment)?

Have you had lymphedema before or received treatment for it?

Yes No

If yes, what treatments have you received for lymphedema?

Compression Bandaging Kinesio Taping Self-Drainage Techniques Compression Garment Use Pneumatic Compression Pump Other (specify)

Patient Goals

What are your primary goals for therapy? Please check all that apply and feel free to add specifics.

Return to Work Able to Drive Return to Sport/Activity Improve Ability to Walk Reduce Pain Improve Strength Improve Balance Increase Flexibility/Range of Motion Manage Swelling/Lymphedema Other (specify)

Please specify any other goals:

Consents and Authorizations

Consent to E-Signature

By typing your name below, you agree that your electronic signature is the legal equivalent of your manual signature on this form. You understand that you are signing this document electronically and it is legally binding.

I agree to use an electronic signature for this form. *

Electronic Communications Consent

I authorize Rise and Recover Therapy Clinic to communicate with me via electronic methods, including email and text messages, for purposes related to my healthcare, such as appointment reminders, scheduling, billing, and general information. I understand that while reasonable efforts are made to protect my privacy, electronic communications may not be entirely secure. I can opt-out of these communications at any time by notifying the clinic.

I consent to receive electronic communications. *

Insurance Verification and Benefits Consent

I authorize Rise and Recover Therapy Clinic to verify my insurance benefits, eligibility, and coverage with my insurance company(ies) for all services provided. I understand that verification of benefits is not a guarantee of payment and that I am ultimately responsible for any charges not covered by my insurance.

I consent to insurance verification and understand my financial responsibility. *

Acknowledgement and Authorization to Receive Health Records and Insurance Benefits

I understand that I am responsible for all charges incurred. I authorize the release of any medical information necessary to process my claims to my insurance company, other healthcare providers involved in my care, or any third party payers. I also authorize and direct my insurance company to pay benefits directly to Rise and Recover Therapy Clinic for services rendered. This authorization remains in effect until revoked by me in writing. A photocopy of this authorization shall be considered as valid as valid as the original.

I acknowledge and authorize the release of records and assignment of benefits. *

HIPAA/Privacy Practices Acknowledgement

I acknowledge that I have received, reviewed, or been offered the opportunity to review Rise and Recover Therapy Clinic's Notice of Privacy Practices, which describes how my protected health information may be used and disclosed.

I acknowledge receipt/review of the Notice of Privacy Practices. *

Contact Authorization

I authorize Rise and Recover Therapy Clinic and its staff to contact me at the phone numbers and email addresses provided for appointment reminders, scheduling, billing, and other treatment-related communications.

I authorize contact for treatment-related communications. *

Cancellation and No-Show Policy

I understand that Rise and Recover Therapy Clinic requires at least 24-hour notice for appointment cancellations or rescheduling. Appointments canceled or missed without 24-hour notice will incur a $75.00 cancellation/no-show fee. This fee is not covered by insurance and will be my direct responsibility. Repeated cancellations or no-shows may result in discharge from the clinic.

I have read and understand the cancellation and no-show policy and agree to its terms. *

Consent to Use Photo/Non-Medical Information for Marketing

I voluntarily consent to Rise and Recover Therapy Clinic using my photo and/or non-medical information (e.g., testimonials about my experience, general progress, but NOT specific protected health information) for promotional, educational, and marketing purposes on their website, social media, brochures, or other clinic materials. I understand that my participation is voluntary and I can revoke this consent in writing at any time. My decision to consent or not will not affect the quality of my care.

I consent to the use of my photo/non-medical information for marketing purposes.

Consent to All Financial Obligations

I acknowledge and accept full financial responsibility for all services rendered by Rise and Recover Therapy Clinic that are not covered by my insurance or other third-party payers. This includes, but is not limited to, deductibles, co-payments, co-insurance, and any services deemed non-covered or medically unnecessary by my insurance company. I agree to pay all charges incurred in a timely manner.

Furthermore, I authorize Rise and Recover Therapy Clinic to charge my credit card or debit card on file for any outstanding balances, including but not limited to co-payments, deductibles, co-insurance, and cancellation/no-show fees, as per the clinic's financial policies.

I understand and agree to all financial obligations. *

Patient Signature

Patient's Full Name (Type to sign) *

Electronic Signature

Date *

Send a copy of my intake information to my email address

Please complete all sections thoroughly to help us provide you with the best possible care.