Sending Patient
Intake Form

PATIENT INTAKE FORM

REFERRAL INFORMATION

During this calendar year (2024), have you had any of the following Rehabilitation Services?

INSURANCE INFORMATION

 

CONFIDENTIAL PATIENT INFORMATION

Personal health history
General current conditions

(Please read all and check all that apply to you)
Recent
Diagnosed Condition
Describe your habits
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*
Click the body part that is painful.

PHYSICAL THERAPY ATTENDANCE POLICY

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 following Cancellation and Missed Appointment Policy:

Cancellation and Missed Appointment Policy

  • If you cannot attend a scheduled appointment, please contact South Pacific Physical Therapy West/ Physical Therapy West at least twenty-four (24) hours prior to the scheduled appointment so that the appointment time may be offered to other patients.
  • 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;
  • Missed Appointment Fees are not covered by insurance and are ​solely patient’s responsibility​. All Missed Appointment Fees are due and payable prior to your next appointment.
  • ​Attention Worker’s Compensation Patients​: Physical Therapy West (PT West)/ South Pacific Physical Therapy (SPPT) is to report any Late Cancellation or No-Show to my Worker’s Compensation Adjuster or Nurse/Case Manager. PT West/ SPPT's may discharge any Worker’s Compensation patient that accumulates two (2) Late Cancellations and/or No-Shows, and that being discharged from physical therapy for poor attendance may affect the outcome of my Worker’s Compensation claim.
I have read, understand, and agree to follow the above Cancellation and Missed Appointment Policy.