LAMORINDA ORTHOPAEDIC & SPORTS PHYSICAL THERAPY
DIRECTIONS: Please print, complete and bring to first appointment
or email as an attachment to email@example.com
Today's Date: Referring Dr.
Patient's last name:
Is this your legal name? Y N
If not, what is your legal name?
Marital status: Single Mar Div Sep Wid
Birth date: Age: Sex: M F
Cell phone number:
Home phone number:
Employer phone number:
Other family members seen here:
Person responsible for bill:
Address (if different):
Contact phone no. area code first:
Is this person a patient here? Y N
Is this patient covered by insurance? Y N
Please indicate primary insurance:
Subscriber's I.D. no.:
Patient's relationship to subscriber: Self Spouse Child Other
Name of secondary insurance (if applicable):
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the therapist. I understand that I am financially responsible for any balance. I also authorize Lamorinda Physical Therapy or insurance company to release any information required to
process my claims.
Please sign and date at the time of initial visit.