Wall Street NY Physical Therapy PC 26 Broadway, Suite 931, NY-10004 Tel: +1 (646) 944-1738 MON – FRI 08:00 AM – 07:00 PM New Patient Form Please fill out completely, print, sign and date the form and bring with you to your first appointment Patient Name: Last First Middle SSN Address City State Zip Email Address Mobile # Date of Birth Referred by Status SMDW Gender FemaleMaleOtherPrefer not to say Occupation Employer Work # Employer's Address City State Zip In Case of an Emergency: Who should we contact? Relationship: Phone #: Reason for Visit: The reason for this visit is a result of: WorkSportsAutoChronicTraumaUnknown When did the condition begin: Is this condition getting worse? YesNoUnchanged Describe what happened: Describe your main complaint & its location: Grade your Primary Complaints (how you feel today): 12345678910 No Pain Unbearable Pain How often are your symptoms present? 0-25%26-50%51-75%76-100% Describe the secondary complaint & its location: Have you been treated by another provider for this condition? YesNo Have you had any spinal X-Rays, MRI or CT Scans for your area(s) of complaint? YesNo list areas taken: Please bring any films or reports related to your condition with you on your initial visit. Who is your Primary Medical Doctor? Phone #: Lifestyle Information: Do you? Smoke? YesNo packs/day Exercise? How often? YesNo Take Vitamins or Supplements? (list below) YesNo Take Medications? (list below) YesNo Drink alcohol? YesNo units/day Wear heel lifts? YesNo Wear orthotics? YesNo Sleep well? YesNo List all medications and/or supplements you take For Women: Do you? Take Birth Control? YesNo Are you Pregnant? Weeks/LMP YesNo Patient Medical Health History: List any allergies to foods, medications, etc.: List any condition(s) you have or ever had: List any past accidents with dates: List any previous surgeries/treatments with dates: Symptoms Survey: Do you currently have or have you ever had any of the following conditions or diseases? Neck Pain or Stiffness YesNo Mid Back Pain or Stiffness YesNo Lower Back Pain or Stiffness YesNo Tension or Migraine Headaches YesNo Tingling or Numbness in Arms / Hands YesNo Tingling or Numbness in Legs / Feet YesNo Shoulder / Elbow / Wrist Pain (Check) YesNo Hip / Knee / Ankle Pain (Check) YesNo Spine Surgeries/Artificial Joints YesNo Neurological Conditions YesNo Psoriatic Arthritis YesNo Family Medical Health History: Do any members of your immediate family have or ever had any medical conditions listed above? If yes, please list: Insurance Information: (Not needed to fill if already provided) Insurance Co.Name: Tel# Address City State Zip Insured's Name: Date of Birth Insured's ID#: Group #: Relationship No-Fault/ Worker Comp Ins. Co: Tel# Address City State Zip Claim #: WCB Case #: Date of Injury I hereby authorize assignment of my insurance rights and benefits to be paid directly to the provider of services rendered at Wall Street NY Physical Therapy PC is the policy of some insurance companies to pay the subscriber (patient) directly in certain cases. fully understand that if I receive any payment directly from my insurance company for services rendered by any provider at Wall Street NY Physical Therapy PC am solely responsible to sign over such insurance checks. In the event that I deposit these checks into my account or negotiate them, I am responsible for reimbursing the provider that rendered these services for an equal amount. Wall Street NY Physical Therapy PC requires all payments in full for services rendered at the time of the visit unless other arrangements have been made with the business manager. If you want to discuss any financial matters, please inform the front desk prior to treatment. We encourage you to inform the front desk if you want to discuss any questions you have regarding our services or billing practices. This promotes a greater confidence and trust between our patients and staff, thus resulting in a more comfortable experience and healing environment. I understand the information in this form and completed it truthfully to the best of my knowledge. I also understand that it is m responsibility to inform this office of any changes in the provided information that may occur in the future. As the parent or legal guardian of the minor listed above, I hereby authorize the providers at this office and their assistants to administer care a necessary. Patient's Signature Clear Relationship Date Wall Street NY Physical Therapy PC 26 Broadway, Suite 931, NY-10004 Call +1 (646) 944-1738 MON – FRI 08:00 AM – 07:00 PM Office Policies Your treatment plan has been prescribed to you based on our experience with your specific type of condition that has produced the best results for our patients in the past. Generally, treatment visits are more frequent during the initial phase of care (first 2-4 weeks) and as objective and subjective findings improve, we recommend a reduction in treatment frequency. However, it is crucial during this initial phase of care that you keep all scheduled appointments for your treatments to be most effective. We have found that patient noncompliance is the primary reason for suboptimal results and frustration for both patient and doctor. If you miss a visit, you should reschedule another appointment immediately so you will follow your weekly treatment plan (i.e., if it is 2 visits per week, then make up that second visit within that week). Our staff prides itself in providing you with the highest standard of care that would otherwise be compromised with noncompliance. Financial arrangements will be clearly discussed with you before beginning care. If you have any questions regarding finances or insurance benefits please bring them to our attention as soon as possible. Clear communication between you and our office staff will result in a more enjoyable healing experience. If you have questions regarding any aspect of your care or have any financial concerns please make an appointment to speak with Sanchu Chacko, the principal of Wall Street NY Physical Therapy PC. He will discuss any questions and concerns you may have and work towards a resolution. Wall Street NY Physical Therapy PC will accept assignment of insurance benefits for you, along with handling the processing and submission of all your claims. This extra service allows you, the patient to focus on your health and wellness rather than being burdened with time consuming paperwork. We encourage you to request a particular provider (chiropractor or massage therapist) that you feel most comfortable with and every effort will be made to schedule you with him/her each visit. However, that provider may be unavailable to treat you on occasion and in that case, you will be scheduled with someone else. As the patient you will benefit from the expertise and specialization provided by other members of the Wall Street NY Physical Therapy PC Healthcare Team. This is what is meant by an integrative approach to healing and wellness. Most of our patients are referred to us from past or existing patients. If the care you receive at our office meets or exceeds your expectations, we ask that you recommend your friends, colleagues, and family. We promise to provide them with the same high standard of care we provide to you. We make every effort to respect your time and we ask that you do the same We ask that you keep all your personal information current, particularly your insurance information, address, and phone numbers. If anything changes, please let us know as soon as possible We welcome you as a patient of Wall Street NY Physical Therapy PC Clear Signature Date Wall Street NY Physical Therapy PC 26 Broadway, Suite 931, NY-10004 Call +1 (646) 944-1738 MON – FRI 08:00 AM – 07:00 PM Consent Agreement I, understand and accept that as part of my patient care at Wall Street NY Physical Therapy PC that this practice originates and maintains health records describing my health history, symptoms, examinations, test results, diagnosis, treatment, and any plans for future care or treatment as a standard of care. I understand that this information will be utilized for professional purposes to assist in developing an appropriate treatment plan and allow effective communication among other health care professionals who may participate in my care. This information will also be provided to third party payers that will include the diagnosis, procedures performed and documentation of those procedures that serve as verification of services rendered. Periodic re-evaluations will be performed to monitor my progress and assess whether appropriate care is being given to me. I understand that I have the right to object to the use of my health information for purposes other than those described in this document. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that Wall Street NY Physical Therapy PC is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the Wall Street NY Physical Therapy PC has already taken action in reliance thereon. I wish to add the following restrictions to the use or disclosure of my health information. I fully understand and accept the terms of this consent. Signature Clear Date
