LAOPPT, INC. INTAKE FORM

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Patient Name

Date Of Birth

YYYY

Gender

Female

Male

Prefer not to say

Other:

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Parent or Legal Guardian Name

If patient is a minor please fill out

Relationship to Patient

If patient is a minor please fill out

Consent To Use Email

Do you provide consent to allow us to communicate via email to confirm appointments, discuss various aspects of your care, and possibly share protected health information? NOTE: We use a secure HIPPA compliant email provider and the information you send to us is secured. Your email provider however may not be secure and may expose your protected health information.

Allow all communication via email

Allow communication only for appointment related reminders

Do not allow email communication

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Address

Home Phone Number

Cell Phone Number

Consent to Use Text Messaging

Do you consent to allow us to communicate with you via text messaging to confirm appointments?

Yes

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Emergency Contact Name

Enter the name of whom we should call in case of emergency

Emergency Contact Phone

Enter the phone number of whom we should call in case of emergency

Referred By

Enter who referred you to our clinic

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Forms

This form was created inside of LA Orthopedic and Pediatric Physical Therapy.