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?*
Emergency Contact:*
Emergency Contact Number:*
Is the patient's injury work related?*
Date on injury:
Patient Employer:
Patient Occupation:
Is 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:
Primary insurance company:*
Primary insurance ID number:
Primary insurance group number:
Secondary insurance company:*
Secondary insurance ID number:
Secondary insurance group number:
Allergies (including latex):*
Respiratory problems, Asthma:*
Dizziness, ringing in ears:*
Neck problems, shoulder, arms or head problems:*
Low back problems:*
Leg problems:*
Heart problems:*
High blood pressure:*
Blood clots:*
Abnormal blood count:*
Tumors or cancer:*
Nausea or vomiting:*
Digestive problems:*
Urinary problems:*
Metal implants (screws, plates, etc.)*
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:*