Accessible Physical Therapy Services, LLC. Registration Page 1 - Must be completed by all patients. Please Print. Patient Last Name
Date of Injury Cause of Injury (check one)
Patient First Name Patient Middle Initial Social Security # Age
Auto Accident Date of Birth Sex:
Male
Work Related Illness
Female
Other
Guardian (If patient minor) Guardian Date of Birth
Address Apartment # City
State
Zip
City
State
Home Phone # Cell Phone #
Employer Employer Phone #
Referring Physician Primary Care Physician
Emergency Contact Phone #
Relationship to Patient
Zip
Check this box if patient does not have health insurance Primary Insurance Company Policy #
Group
Claims Address Line1 Claims Address Line2 City
State
Zip
Policy Holder Name
Date of Birth
Relation to Patient
Policy Holder Social Security #
Secondary Insurance Company Policy #
Group
Claims Address Line1 Claims Address Line2 City
State
Zip
Policy Holder Name
Date of Birth
Relation to Patient
Policy Holder Social Security #
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Accessible Physical Therapy Services, LLC to release any information required for processing my claims.
Patient/Guardian Signature
Date
Office Use Only Diagnosis Location
Therapist
Reviewed By