OCPT Client Info & Background
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Email *
Client's Full Legal Name *
Preferred Nickname
Date of Birth *
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Telephone Number *
Address (including unit, city, and zip code) *
How did you hear about OCPT? *
Do you have a prescription? *
If you were referred by a Physician, please enter their name here *
If you do NOT have a referral for Physical Therapy. Please provide a doctor's name you are currently being treated by. If you are not working with any doctor, please enter N/A. 
Is your physical therapy case a part of an on-going lien? An example of a lien would be an accident case that you are also working with a lawyer.  *
What is your primary insurance company? If none, please enter "self-pay." *
Please enter your full insurance ID number. (Type NA if self-pay) *
Reason for visit with OCPT: *
Required
On what date did your current condition/complaint begin? *
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Describe your pain to us i.e. location of pain and type of pain (sharp, dull, numbness, shooting)
Level of pain you are experiencing for your current complaint *
No pain
You should be in the hospital
What are your limitations because of your current complaint? *
Required
What activities or movements aggravate your pain?
What activities or movements give you pain relief?
Indicate which of the following you have had, or have at the present. Check all that apply. *
Required
Previous orthopedic surgeries? (type and year)
Other surgeries we should know about? (type and year)
Are you taking any pain medication?  If yes, what they are and how often you are taking them.
Emergency Contact (Name, Relationship, and Phone Number)
Would you like to be sent e-mail reminders for your appointments?
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Consent to treat: I consent to receive rehabilitation therapy treatment and any supplementary services that are deemed medically necessary or appropriate by my therapist and/or treating physician. However, I understand that the practice of rehabilitation therapy is not an exact discipline and I acknowledge that no guarantees have been made to me regarding treatment and/or the treatment results from the rehabilitation therapy. *
Required
Consent to treat (if under 18 years old), please provide Parent/ Legal Guardian Full Name:
Photo and Video Release: I hereby grant OCPT permission to use my likeness in a photograph or video in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of the OCPT and will not be returned. *
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