Adrift PT - Patient Information Form

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Updated 5/25/22

Today’s Date *

Name *

Date of Birth *

Phone *

Emergency Contact Info

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone *

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? *

Have you been treated for this condition before? When, where, and by whom? *

Other Symptoms/Pain Information (general aches and pains, underlying related health conditions). *

Are you taking any of the following medication‘s? *

Coumadin

Lavonox

Heparin

Aspirin

Required

When did your pain start? *

Cause/onset:

Additional Information

Do you have allergies to oils, creams, etc? *

Yes

May I on occasion send an email newsletter? *

Yes

How did you hear about me? *

Submit

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