Lamorinda Orthopaedic & Sports PT - Patient Information
Lamorinda Orthopaedic & Sports PT - "Rehabilitation for the Orthopedic Patient"
LAMORINDA ORTHOPAEDIC & SPORTS PHYSICAL THERAPY
  REGISTRATION FORM
 
DIRECTIONS: Please print, complete and bring to first appointment or email as an attachment to [email protected].
 
Today's Date:        Referring Dr.
 
PATIENT INFORMATION
 
Patient's last name: 
First: 
Middle: 
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
Address: 
Cell phone number: 
Home phone number:
Email Address:
 
Occupation: 
Employer: 
Employer phone number:
 
Other family members seen here:
 
INSURANCE INFORMATION
 
Person responsible for bill: 
Birth date: 
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 name: 
Subscriber's I.D. no.: 
Birth date: 
Group no.: 
Policy no.: 
Co-payment:
 
Patient's relationship to subscriber: Self   Spouse   Child    Other
 
Name of secondary insurance (if applicable): 
Subscriber's name: 
Group no.: 
Policy no.:
 
EMERGENCY CONTACT
 
Name: 
Phone Number:
 
 
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.
 
Patient/Guardian signature: 
 
Print Name:
 
Date:
 
 
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