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FREE SCREEN
REQUEST APPOINTMENT
Arizona Orthopedic Physical Therapy
Physical Therapy
AzOPT
The AzOPT Difference
Physical Therapy
Aquatic Therapy
What We Treat
How We Treat
Free Assessments
KIDS PLACE
The Kids Place Difference
Pediatric Physical Therapy
Pediatric Occupational Therapy
Pediatric Speech Therapy
Pediatric Feeding Therapy
Pediatric Aquatic Therapy
Mariah’s Miracle
LOCATIONS
AzOPT Aquatics
AzOPT Buckeye
AzOPT Gilbert
AzOPT Glendale
AzOPT Goodyear
AzOPT Prescott
Kids Place Central (Phoenix)
Kids Place East (Gilbert)
Kids Place North (Prescott)
Kids Place West (Goodyear)
FOR PATIENTS
AzOPT FAQs
Kid’s Place FAQ’s
Direct Access
New Patient Forms
Insurance and Billing
Pay My Bill
Notice of Privacy Acts
EDUCATION
Blog
Newsletters
ABOUT
Our Story
Our Team
Community Involvement
Careers
Contact
AzOPT
The AzOPT Difference
Physical Therapy
Aquatic Therapy
What We Treat
How We Treat
Free Assessments
KIDS PLACE
The Kids Place Difference
Pediatric Physical Therapy
Pediatric Occupational Therapy
Pediatric Speech Therapy
Pediatric Feeding Therapy
Pediatric Aquatic Therapy
Mariah’s Miracle
LOCATIONS
AzOPT Aquatics
AzOPT Buckeye
AzOPT Gilbert
AzOPT Glendale
AzOPT Goodyear
AzOPT Prescott
Kids Place Central (Phoenix)
Kids Place East (Gilbert)
Kids Place North (Prescott)
Kids Place West (Goodyear)
FOR PATIENTS
AzOPT FAQs
Kid’s Place FAQ’s
Direct Access
New Patient Forms
Insurance and Billing
Pay My Bill
Notice of Privacy Acts
EDUCATION
Blog
Newsletters
ABOUT
Our Story
Our Team
Community Involvement
Careers
Contact
Form: New Patient Information
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*
" indicates required fields
Step
1
of
6
16%
Which clinic is your scheduled evaluation?
*
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AzOPT Buckeye
AzOPT Gilbert
AzOPT Glendale
AzOPT Goodyear
AzOPT Prescott
Name
*
First
Last
Patient Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Patient DOB
*
MM slash DD slash YYYY
Gender
*
Male
Female
Email
*
Home Phone
*
Cell Phone
Parent/Guardian Name (if patient under 18)
Primary Physician Name
Primary Physician Phone
Referring Physician Name
Referring Physician Phone
How did you hear about AZOPT?
*
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Doctor - Provided Options
Doctor - Direct Referral
Returning Patient
Insurance
Family/Friend
Word of Mouth
Community Event
Internet Search
Social Media- FB, Newsletter
Advertisement
Fitness Partner
AZOPT Employee
Drive By
Yellow Pages
Other
Please provide additional details about your referral so we can show our appreciation:
AZOPT prefers to keep its business “in the family” when possible. Are you involved in a business that could develop a relationship with AZOPT (i.e. graphic design, office supplies, printing, construction, etc.)?
Emergency Contacts
Primary Emergency Contact Name
*
Primary Emergency Contact Relationship
*
Primary Emergency Contact Phone
*
Secondary Emergency Contact Name
*
Secondary Emergency Contact Relationship
*
Secondary Emergency Contact Phone
*
Is this injury related to a car accident?
*
Yes
No
If your injury is related to work or an auto accident, please provide our office with the details of your insurance coverage for this incident.
Primary Insurance Information
Insurance Company Name
*
Subscriber Name
*
Subscriber DOB
*
MM slash DD slash YYYY
ID Number
Group/Policy Number
Customer Service Phone Number
Located on back of insurance card
Secondary Insurance Information
Do you have secondary insurance?
*
Yes
No
Insurance Company Name
Subscriber Name
Subscriber DOB
MM slash DD slash YYYY
ID Number
Group/Policy Number
Customer Service Phone Number
Located on back of insurance card
Patient History
Check the box for each item that you have experienced previously:
Alcohol/Drug Addictions
Arthritis/Rheumatism
Asthma/Wheezing
Back Trouble
Blood Disease or Anemia
Breathing Difficulties
Broken Bones
Cancer, Tumor or Growths
Chest Pain or Pressure
Chronic Cough
Diabetes
Dislocated Joints
Dizziness or Fainting
Elbow/Shoulder
Emotional Problems
Epilepsy, Fits or Convulsions
Eye Trouble or Injury
Foot Trouble
Frequent/Severe Headaches
Head, Neck or Spinal Injuries
Hearing Difficulty
Heart Trouble or Murmur
Hernia (Rupture)
High Blood Pressure
HIV/AIDS
Jaundice or Hepatitis
Kidney Disease or Stones
Knee Trouble
Neuritis/Pinched Nerves
Osteoporosis
Painful/Stiff Joints
Pneumonia/Pleurisy
Polio or Paralysis
Rheumatic or Scarlet Fever
Swelling of Ankles
Trouble Phlegm or Spitting Blood
Tuberculosis
None/Not Applicable
If you marked YES to any of the above, please indicate your age when you first experienced each problem:
Check the box to indicate YES for the following items:
Have you ever had any serious ill effects from activities you have done?
Has your activity ever had to be limited or restricted on account of your health?
Do you have any allergies or past allergic reactions?
Do you have any condition, which may require limits to your daily activities?
Have you ever had any surgical operation, or been advised to have one?
Have you ever had an injury or ailment to your neck and/or back?
Have you ever had an injury or operation to either knee or shoulder?
If you marked YES to any of the above, please explain:
Do you now (as of 1 month ago) smoke cigarettes?
Yes
No
How many years have you smoked (did smoke) cigarettes?
Are you pregnant?
*
Yes
No
Please check any and all medications you are currently taking:
Pain Medications
Acetaminophen
Advil
Aleve
Aspirin
Celebrex
Cymbalta
Darvocet
Dilaudid
Elavil
Excedrin
Flexeril
Hydrocodone
Ibuprofen
Lortab
Lyrica
Lyrica
Motrin
Naproxen
Neurontin
Norco
Nucynta
Opana
OxyContin
Paracetamol
Percocet
prednisone
Relafen
Toradol
Tramadol
Tylenol
Ultram
Vicodin
Vistaril
Voltaren
Hypertension
Aldactone
Avapro
Azor
Cardizem
Diovan
Lasix
lisinopril
Lopressor
Lotensin
Nitro
Anxiety/Depression
Ativan
Buspar
Compazine
Cymbalta
Dilantin
Lexapro
Paxil
Pristiq
Prozac
Risperdal
Valium
Wellbutrin
Xanax
Zoloft
Gout
Aloprim
Uloric
Zyloprim
Osteoporosis
Actonel
Boniva
Climara
Evista
Fosamax
Prempro
Reclast
Anticoagulants
Coumadin
Heparin
Warfarin
Antivertigo Drugs
Antivert
Compazine
Meclizine
Raglan
Zofran
Please list any other medications you are currently taken that were not listed above:
I, the undersigned, hereby request and consent to the performance of therapy, including examination and diagnosis, on me by Arizona Orthopedic Physical Therapy, PLLC and other physical therapists and occupational therapists under Arizona Orthopedic Physical Therapy, PLLC supervision. I consent to the treatment plan and intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.
Signature
*
Patient / Parent or Guardian Printed Name
*
Date
*
MM slash DD slash YYYY
Financial Policies
AZOPT is committed to providing the best possible care, and therefore, your clear understanding of our financial policy is important to our professional relationship. Please ask if you have questions about our fees, financial policy, or your financial responsibility.
AZOPT will request a photocopy of the front and back of your insurance identification card and driver’s license. Please update your card with any additional information your insurance company provides, which will facilitate the submission of claims on your behalf. It is your responsibility to inform us of any changes to your policy. We will bill your insurance company on your behalf as a courtesy.
Co-Payment/Co-Insurance
We must collect your carrier-designated co-pay at the time of service. Refusal to abide by this agreement may result in termination of your coverage.
AZOPT will calculate an estimated co-payment or co-insurance based on your insurance policy. This amount will be due at the time of each appointment.
Missed Appointments
Patients who do not show up for an appointment, or call to cancel with less than 24 hours’ notice have impacted other patient’s ability to obtain timely medical care. Therefore, subject to the individual patients’ insurance contract, we reserve the right to charge a $50.00 fee for no-show or same-day canceled appointments.
Returned Checks
If a check is used as your form of payment, and that check is returned due to insufficient funds or the payment has been stopped, you will be charged a $25.00 fee in addition to the amount of the check.
Insurance
We will gladly bill and accept payment from your health insurance plan. Any amounts not covered by your insurance carrier are your responsibility.
Communication between AZOPT and our patients help us succeed in providing the best care. Please advise us if your insurance company has pre-certification and/or prior authorization requirements and/or policy restrictions and limitations.
Payments
You are responsible for any amount not covered by your insurance carrier. All co-payments and deductible amounts are due at the time of service. For your convenience, we do accept all major credit cards, checks, money orders, and cash.
Patient or Guarantor
I have read and understand the above. I hereby authorize Arizona Orthopedic Physical Therapy, PLLC to submit claims to my insurance carrier. I hereby authorize direct payment of benefits, otherwise payable to me, to be made payable to Arizona Orthopedic Physical Therapy, PLLC. I understand I will be responsible for payment of any amounts not covered by my insurance carrier, including, but not limited to, co-payments and deductibles.
Signature
*
Patient / Parent or Guardian Printed Name
*
Date
*
MM slash DD slash YYYY
Authorization for the Release of Medical Records
I hereby authorize Arizona Orthopedic Physical Therapy, PLLC to release the medical record(s) of:
*
Patient's DOB
*
MM slash DD slash YYYY
For the purpose of continued treatment and billing/re-assignment of benefits, this allows AZOPT to bill on your behalf, and for the payment to be sent directly to AZOPT, to:
Arizona Orthopedic Physical Therapy, PLLC
14557 W. Indian School Rd. #500
Goodyear, AZ 85395
Phone: 623-242-6908
Fax: 623-242-6909
Signature of Patient/Guardian:
*
Printed Name
*
Date
*
MM slash DD slash YYYY
Notice of Privacy Practices
Your name and signature below indicate that you have received a copy of and/or have been directed to the Notice of Privacy Practices by Arizona Orthopedic Physical Therapy, PLLC, on the date indicated. If you have any questions regarding the information set forth in AZOPT’s Notice of Privacy Practices, please do not hesitate to ask an AZOPT representative.
Signature of Patient/Guardian:
*
Printed Name
*
Date
*
MM slash DD slash YYYY
Photo Consent Release
I would like to extend permission to Arizona Orthopedic Physical Therapy, PLLC (AZOPT) to use my:
Name
Testimonial
Image/photograph
in publications and advertisements produced by or for AZOPT. I understand that these publications will also be placed on websites managed by AZOPT for public relations and advertising purposes. I understand that the publication may appear on the Internet, the publication may appear in print, electronic, or video media, and the publication may enable readers to identify me. I understand this consent is valid until I provide written notice stating otherwise.
Signature of Patient/Guardian:
*
Printed Name
*
Date
*
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
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