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Adrift PT - Patient Information Form
Updated 5/25/22
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* Indicates required question
Email
*
Your email
Today’s Date
*
Your answer
Name
*
Your answer
Date of Birth
*
Your answer
Phone
*
Your answer
Emergency Contact Info
Emergency Contact Name
*
Your answer
Emergency Contact Relationship
*
Your answer
Emergency Contact Phone
*
Your answer
AdriftPT does not process insurance payments, but you may request a bill indicating the treatment you have received in order for you to submit it to your insurance company for reimbursement.
*
I understand that insurance reimbursement is not guaranteed. I understand that Health insurance reimbursement is my responsibility.
What are the symptoms that brought you here today?
*
Your answer
Have you been treated for this condition before? When, where, and by whom?
*
Your answer
Other Symptoms/Pain Information (general aches and pains, underlying related health conditions).
*
Your answer
Are you taking any of the following medication‘s?
*
Coumadin
Lavonox
Heparin
Aspirin
No
Required
When did your pain start?
*
Your answer
Cause/onset:
Your answer
Additional Information
Do you have allergies to oils, creams, etc?
*
No
Yes
May I on occasion send an email newsletter?
*
Yes
No
How did you hear about me?
*
Your answer
Send me a copy of my responses.
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