SUNSHINE PHYSICAL THERAPY CLINIC

Patient Registration Form (Page 2)

 

 

 

 

Have you given Power of Attorney or Durable Power of Attorney to anyone?                   YES     NO

 

            If yes, please give name:  _______________________________________

 

Are you currently receiving Home Healthcare?     YES     NO

 

            If yes, name of agency:  ________________________________________

 

Have you received Home Healthcare in the past 30 days?      YES           NO

 

            If yes, name of agency:  ________________________________________

 

Are you currently receiving Physical, Occupational or Speech Therapy

at another facility or Doctor’s office?                    YES     NO

 

Have you received Physical, Occupational or Speech Therapy

at another facility this calendar year?                                 YES     NO

 

            If yes, number of visits?  _______

 

Injury related to Automobile Accident?    YES     NO     State accident occurred: 

 

Is this a liability injury?                             YES     NO

 

            If yes, Attorney Name:  __________________            Telephone:  ________________

 

Injury related to employment?                  YES     NO

 

            Date of Accident/Injury:   ________________

 

            If Worker’s Comp, Employer Name:  ______________________________

 

            Employer Address:  _____________________________________________________________  

 

                                             _____________________________     Telephone:  ____________________

 

                                             City:  _________     State:  _________     Zip Code:  ________

 

 

 

SIGNATURE:  _____________________________________________________