New Patient Registration FormPlease complete the new patient form to the best of your ability.Step 1 of 10 - Completing for10%Are you completing this for yourself or someone else? I am an adult completing this for myself I am an adult, but I am completing this for a child I am an adult, but I am completing this for another adult I am a child and I am very independent BPT Staff- Adult Appointment BPT Staff- Pediatric AppointmentAdmin name completing form* Melissa Dani Tova Eunice Abraham HPH Ziv Joe NameName of the patient First Last Patient Date of Birth* Month Day Year Please provide the patients birthday to allow us to check medical insurance benefitsGender Male Female Prefer Not to AnswerAddressPlease only enter Numbers or Letters; no special characters Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code What is your relationship to the patient?What is your name ?What is your name ?Cell Phone*Home PhoneEmail* Enter Email Confirm Email Type of Visit* PT- Physical Therapy OT- Occupational Therapy ST- Speech Therapy Other- Don't knowThis field is hidden when viewing the formDo you have insurance - old Yes NoDo you have insurance?* Yes NoPrimary Insurance Name*Medicare, BCBS, UHC etc.Name and DOB of primary insured*Primary Insurance phone #*Primary Insurance ID #*Primary Insurance Group #*Do you have secondary insurance? Yes NoSecondary Insurance Name*Medicare, BCBS, UHC etc.Name and DOB of Secondary insured*Secondary Insurance phone #*Secondary Insurance ID #*Secondary insurance Group #*This field is hidden when viewing the formPrimary Insurance InformationPlease list the policyholder name and date of birth if different from patientPrimary Insurance Name (Medicare, BCBS, UHC etc.)Name and DOB of primary insuredInsurance phone #ID #Group #This field is hidden when viewing the formSecondary Insurance InformationSecondary Insurance Name (Medicare, BCBS, UHC etc.)Insurance phone #ID #Group #This field is hidden when viewing the formSecondary Insurance InformationSecondary Insurance Name (Medicare, BCBS, UHC etc.)Insurance phone #ID #Group #Do you have a prescription for PT, OT, or Speech?* Yes No Not yetPrescription Detail*As of Sept 1, 2019 Texas Law will allow limited direct access to physical therapy without prescription from a doctor. This means we can evaluate and treat you for 15 consecutive days prior to consulting with an MD, DO, NP, PA, DDS, DPM, or DC. I will bring my prescription My prescription has been faxed/emailed to your office I am not sure where my prescription isPrescription UploadUpload your prescription hereMax. file size: 64 MB.Do you have a primary or referring doctor?This can be an MD, DO, DPM, DDS, DC, PA, NP or PMR Yes, I have a primary or referring doctor No, I do not have a doctor or referring providerPrimary Doctor Information*please list your doctor's information so we can communicate as required by Texas State lawDoctor First NameDoctor Last NameOffice NameOffice Phone Number Please describe why you need physical therapy or list your diagnosis ICD-10Include any diagnosed you would like us to address ie: Back pain, difficulty walking, rotator cuff tear, stiffness in joints, cancer, fraily etc.Do you currently take any medication ? Yes No Yes but not for the reason I am seeking therapyHow did you hear about us?* My doctor My friend Google / Internet Advertisement Returning Patient Social Media Insurance CompanyName of friendPlease provide the name of the friend who referred you so we can personally thank them.Appointment RemindersHow would you like to receive appointment reminders? Phone Text EmailAdministrative NotesAppointment details*Please complete if you scheduled the patient.Day/Date/Time of EvaluationName of TherapistDiscipline (PT/OT/SPEECH)Phone/Fax/Walk-inAppointment location*Please complete if you scheduled the patient. Cypress Bellaire SugarlandAppointment request*When Would you like to come in?Preferred DayPreferred timeDiscipline (PT/OT/Speech)Texas Board of Physical Therapy Examiners333 Guadalupe, Ste 2-510 512/305-6900 512/305-6951 fax Austin, Texas 78701-3942 http://www.ptot.texas.gov Physical Therapy Treatment without Referral Disclosure Please read carefully and acknowledge below:I understand that physical therapy treatment without a referral will be based on the physical therapist’s examination and evaluation of my current condition which may result in identification of movement and mobility dysfunction. I understand that the physical therapist will not diagnose an illness or disease, and that physical therapy is not a substitute for a medical diagnosis. I understand that if a medical diagnosis has already been established by a qualified healthcare practitioner, the physical therapist will take it into consideration during the evaluation process. I understand that the physical therapy plan of care developed by the physical therapist may not be based on radiological imaging. I understand that if images have previously been obtained, the physical therapist may use the information as part of the evaluation process. I understand that if the physical therapist identifies a need for radiological imaging, the physical therapist may recommend that radiological imaging be obtained. I understand that my health insurance may not cover physical therapy services if provided without a referral from a qualified healthcare practitioner. I acknowledge that I have received the above disclosure.SignatureDate Signed MM slash DD slash YYYY Δ
