Patient Intake Form

Please fill this form entirely before your first visit. Information entered here is secured.

By submitting this form you are agreeing  to our following terms and conditions

1. Consent to Treatment: I consent to rehabilitation and related services at Healing Touch Physical therapy & Rehabilitation. In so doing, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching, and/or direct contact of a sensitive nature.
2. Treatment of Minor: I, as a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.
3. Liability: I know and agree that Healing Touch Physical Therapy and Rehabilitation P.C. is not responsible for loss or damage to personal valuables.
4. Authorization of Payment: I hereby assign all benefits directly to Healing Touch Physical Therapy and Rehabilitation P. C. and authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the services I received, I will be financially responsible for payment.
5. Appointment: I understand that I need to inform the office of any cancellations 24 hrs prior to any scheduled appointment. There is a mandatory fee of $40 for no shows. The fee must be paid before making any future appointments with us. (Do not be rude and inconsiderate of others who want to make an appointment).