Select Service Desired: Physical Therapy Occupational Therapy / Hand Rehabilitation     Referring Doctor: Primary Care Doctor:         Patient's Name: Address:     City/State/Zip Code: ,  Home Phone: Work Phone: Email: Date of Birth: (mm/dd/yyyy) SS#: Marital Status: S   M   W   D Injured Area: Onset: Emergency Contact: Telephone Number:         HAVE YOU RECEIVED WITHIN THE PAST YEAR, OR ARE YOU CURRENTLY RECEIVING ANY OF THE FOLLOWING? Physical/Occupational Therapy Yes No If Yes, # Of Visits Chiropractic Care Yes No If Yes, # Of Visits Physiatrist (Doctor Of Physical Medicine) Yes No If Yes, # Of Visits Home Health Care Yes No If Yes, Date Of Discharge         SELECT PRIMARY REASON FOR CHOOSING THIS FACILITY: Billboard Community event Doctor recommended Employer directed Friend or relative Hours (convenient) Location Newspaper Previous patient Radio Tv – cable Web Site Yellow pages /       telephone book Other    PRIMARY - HEALTH INSURANCE Insurance Name: Telephone Number: Policy Holder: Date of Birth: Relationship: Policy Holder's ID No: Group #:         SECONDARY - HEALTH INSURANCE Insurance Name: Telephone Number: Policy Holder: Date of Birth: Relationship: Policy Holder's ID No: Group #:   IF WORK RELATED INJURY: Employer at time of injury: Date of Injury: Employer Address: Telephone Number: Claim Number: Insurance Carrier: Telephone Number:         IF AUTO ACCIDENT RELATED INJURY: Insurance Carrier: Date of Injury: Telephone Number: Claim Number:         GUARDIAN OR RESPONSIBLE PARTY (IF PATIENT IS UNDER 18 YRS OLD): Name: Relationship to Patient: Address: Home Phone: Work Phone:         Preferred Day: Monday Tuesday Wednesday Thursday Friday First Available     Preferred Time: Morning Afternoon Early Evening First Available     Preferred Location: Cheswick/Springdale New Kensington/Arnold Lower Burrell Leechburg / Kiski Area Deer Lakes / Russellton Sarver Area Kittanning New Brighton             The information that you have submitted will be reviewed and we will contact you by telephone to confirm your appointment time and date. This information is secure and will be held in strict confidence in accordance with all state and federal laws. It is considered part of your medical record and cannot be released without your written permission. Your insurance information will be verified to determine the allowable coverage and any out of pocket expense.

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