New Patient Form

Patient Name:*

Patient Guardian:

Patient SSN Number:Patient Home Phone:


Patient Cell Phone:*


Patient E-mail:Patient date of birth:* /  / Patient Sex:*Patient Address:*
Which location would you like to attend: *Has patient received physical therapy in this calender year?*Does patient currently receive any home care services?*1/6Emergency Contact:*


Emergency Contact Number:*


2/6Is the patient's injury work related?*Date on injury: /  / Patient Employer:

Patient Occupation:

3/6Is the patient's injury due to an auto accident?*Date of auto accident: /  / Accident claim number:

Auto company name:

Case manger name:

Case manager number:


4/6Primary insurance company:*

Primary insurance ID number:

Primary insurance group number:

Secondary insurance company:*

Secondary insurance ID number:

Secondary insurance group number:

5/6Allergies (including latex):*Headaches:*Respiratory problems, Asthma:*Dizziness, ringing in ears:*Neck problems, shoulder, arms or head problems:*Low back problems:*Leg problems:*Heart problems:*High blood pressure:*Diabetes:*Blood clots:*Abnormal blood count:*Arthritis:*Tuberculosis:*Tumors or cancer:*Nausea or vomiting:*Digestive problems:*Urinary problems:*Metal implants (screws, plates, etc.)*Pacemaker:*Pregnant: are you pregnant? Is there a possibility?*Please explain if you picked YES for any of the above:I hereby certify all the options and the information I entered is correct, Max Rehab is not responsible for any missing or incorrect information.*Please sign your name:*

Today's Date:*6/6