NEW PATIENT INFORMATION

Date (todays date):*
MM slash DD slash YYYY
Name:*
First Last
Birthdate:*
MM slash DD slash YYYY
Sex:*
- MALE
- FEMALE
Age:
Please enter a number from 0 to 120.
Email:*
Enter Email Confirm Email
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone:
Work Phone:
Home Phone:
Primary Care Physician Name:
Physician Phone #:
When is the last time you were seen by physician?

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HIPAA INFORMATION RELEASE AUTHORIZATION
Effective starting as of (Today’s Date):*
MM slash DD slash YYYY
In accordance with the new HIPAA privacy laws, Free Motion Physical Therapy can no longer discuss any protected health information with any person other than the patient, doctor, insurance company and/or specified person(s). If you would like your information released to your spouse or any other person, you need to sign a records release form. We appreciate your cooperation in helping maintain patient confidentiality.
I (Name)*
First Last
hereby authorize Free Motion Physical Therapy to release any information (if necessary), including reminders of appointments, the diagnosis and records of any treatment, examination, or evaluation rendered to the undersigned patient, and all financial records to:
Release to persons listed below (Click + to Add More):
Name Relationship
HIPAA PRIVACY PRACTICES ACKNOWLEDGEMENT
I acknowledge and understand that Free Motion follows the HIPPAA Privacy Act to keep my info secure and that at any time I can request a copy of the HIPPA Patient Privacy notice.
Signature (sign here)*
Agreement!*
- Click here to agree to the above terms
By filling in the signature field above and clicking this checkbox I agree to allow this release.

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IN CASE OF EMERGENCY, CONTACT:

Name	Relationship