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Wolfe Physical Therapy Intake Forms
The indicated questions are required to be filled out prior to your initial examination
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Patient Information
Last Name, First Name.         *

Date of Birth:  

 *
MM
/
DD
/
YYYY
Sex/Gender:      *

Mailing Address

 *

Phone Number

 *

Email Address

Physician Information
Referring Physician *
Primary Care Physician
Insurance Information
Primary Insurance Company
Primary Insurance ID# *
Insurance Policy Holder Name/Relationship to Patient.    *
Insurance Policy Holder Date of Birth.
 *
MM
/
DD
/
YYYY
Secondary Insurance Company
Secondary Insurance ID:#
Medical History
What medication are you currently taking? (please add dosages) 
Past Medical History (Check all that apply) *
Required
Past Surgical History *
Please Indicate if you have any of these concerns
Region(s) of pain/ dysfunction? (ex: low back, right knee, left shoulder, etc.)
Approximately, when did your problem/injury occur?
MM
/
DD
/
YYYY
Was there an incident associated with your problem/injury? If so, explain.
What is the intensity of your pain at its worst since onset? 
No Pain
So much pain that you had to call an ambulance or visit an emergency room
Clear selection
What is the intensity of your pain on average throughout the day?
No Pain
So much pain that you had to call an ambulance or visit an emergency room
Clear selection
What is the intensity of your pain at its best? 
No Pain
So much pain that you had to call an ambulance or visit an emergency room
Clear selection
What, if anything, makes your symptoms better?
Have you undergone any special test, or imaging for your condition?
If you have had any imaging, please describe the results/diagnosis    
What is your occupation? How many hours a week do you work? 
Do you exercise regularly? If so, what type of exercise and how often? 
How many hours of sleep do you get on average each night? How would you rate quality of your sleep?    
Is there anything else we should know?
Emergency Contact Name  *
Emergency Contact Number *
Card on File
By filling out this form below, you are consenting for us to charge your card for any additional payment required after billing your insurance and for any no show/late cancellation fees. (copay, coinsurance, late fees, etc.)
Name(Last, First) *
Card Number *
Expiration Date *
Security Code *
Email  *
Billing Zipcode *
Day 1 Informed Consent to Treatment
The following forms are required to begin Physical Therapy Services
Last name, First name *
Informed Consent to Treatment 

I understand that I will be participating in private,

one-on-one physical therapy, incorporating hands-on treatment, manual passive

stretching, spinal mobilization, cupping, dry-needling, and traditional conservative

treatment techniques so that I can improve my strength, endurance, flexibility,

balance, core strength, and overall health and wellness.

I understand that my physical therapist is licensed in the State of Texas and is

educated and highly-trained in the areas above.

By signing below, I am giving my consent to treatment ("informed consent"). And,

I also consent for treatment to occur in my home, gym, workplace, hotel room, or

other location previously agreed upon.

I have been instructed by my physical therapist to alert my therapist of any

special needs, injuries, preferences, or considerations prior to starting the first

visit evaluation and treatment, as these could affect my safety and security

during the treatment process.

I understand that by signing below, I release this physical therapist of all liabilities

for my health and safety during my participation in this treatment process.

I only provide this release with the understanding that my instructor is fully

trained and upholds an active license to perform physical therapy in the State

of Texas. I further acknowledge that by typing my name, this is considered a legal binding document.

(please type your full name below): 

 *
FEDERAL HIPAA NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Dr. Thomas Wolfe, PT, DPT, CSCS License # 1342296
Dr. Kennedi Henneberger PT, DPT License # 1356870
Dr. Nicole Oberdorf PT, DPT License #1304196
Dr. Keri Jones PT, DPT License #1263697
Dr. Madison Ryan Fisher, DPT #1406767
Dr. Ellen Jordahl, DPT #1310133
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

"We: refers to Thomas Wolfe, PT, DPT, CSCS or Kennedi Henneberger, PT, DPT or Nicole Oberdorf, PT, DPT or Keri Jones, PT, DPT, Dr. Madison Ryan Fisher, DPT, Dr. Ellen Jordahl, DPT 

"You" or "yours" refers to any individual receiving treatment by Thomas Wolfe, PT,

DPT, CSCS or Kennedi Henneberger PT, DPT or Nicole Oberdorf PT, DPT or Keri Jones PT, DPT, Dr. Madison Ryan Fisher, DPT, Dr. Ellen Jordahl, DPT . 

Employees Federal law - means the Health Insurance Portability and Accountability Act and related

privacy rules -- requires Thomas Wolfe, PT, DPT, CSCS or Kennedi Henneberger PT, DPT or Nicole Oberdorf PT, DPT, or Keri Jones PT, DPT, Dr. Madison Ryan Fisher, DPT, Dr. Ellen Jordahl, DPT  to keep your health

information private. We are not allowed to use or disclose it unless we receive your

permission or unless permitted by law. Federal law requires us to give you this Notice of

our legal duties and privacy practices. This Notice is to inform you of uses and disclosures

of your health information that we may make. It also informs you of your rights and our

duties with regard to this health information.

We must follow the terms of this Notice. We do reserve the right to change the terms of this

Notice and make the new Notice provisions apply to all the health information we keep.

This includes health information we had prior to any change in this Notice. We must

promptly change this Notice when there is a material change to our uses or disclosures,

your rights, our duties and other related circumstances. To receive such Notices by email,

you should tell the contact listed at the end of this Notice.

 

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Federal law permits us to use and disclose protected health information for purposes of

treatment, payment and health care operations as those terms are defined under federal

law. We will comply with any state or federal law that is more restrictive as to our uses and

disclosures of protected health information.

There are also times when federal law permits or requires us to use or disclose your

information without your written permission.

Additionally, where appropriate, we may disclose protected health information to a group

health plan or plan sponsor in accordance with federal law.

 

Permitted Disclosures:

We may not make all of the uses and disclosures listed here, but federal law permits use or

disclosure of your information without your permission

• When we disclose your information to you.

• To third party non-Wolfe Physical Therapy PLLC associates that perform services for us or on our

behalf.

• Where disclosure is required by law.

• To a public health authority authorized by law to collect or receive your information to

prevent or control disease, injury or disability or when reviewing reports of child abuse or

for the conduct of other authorized public health activities and responsibilities.

• To a health oversight agency for such activities.

• For judicial and administrative proceedings.

• To a law enforcement official for a law enforcement purpose.

• To a medical examiner for the purpose of identifying a deceased person, determining the

cause of death, or other duties authorized by law.

• To organ donor organizations in order to aid in such donations.

• For certain research purposes authorized by and subject to federal law.

• To avert a serious threat to health or safety.

• To government officials regarding military personnel and certain domestic and foreign

government officials for certain functions authorized by federal law.

• To comply with workers' compensation and other similar programs.

Required Disclosures

We must disclose your information when required by the Secretary of the Department of

Health and Human Services to make sure we comply with federal law.

We are also required, with certain exceptions, to provide you with access to inspect and

obtain a copy of your information that we keep. See "Federal Law Provides You with the

Right to Inspect and Copy Protected Health Information" below.

 

INDIVIDUAL RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION

FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO REQUEST RESTRICTIONS:

You have the right to request that restrictions be placed on certain uses and disclosures of

your information.

We are not required to agree. If we do agree, we may not use or disclose any of your

information except where you need emergency treatment. We may end an agreement to

restrict as allowed by federal law. If you wish additional information, you should write to

the contact listed at the end of this Notice.

 

FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO ALTERNATIVE

CONFIDENTIAL COMMUNICATION OF PROTECTED HEALTH INFORMATION: If

you choose to have your information sent to you by a means of your choice or to an address

of your choice, we will do so if the request is reasonable. You must clearly state that

disclosure of all or any part of your information could endanger you if not sent per your

choice. Any such request should be sent in writing to the contact listed at the end of this

Notice. If you wish additional information, you should write to the contact listed at the end

of this Notice.

 

FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO INSPECT AND COPY

PROTECTED HEALTH INFORMATION: You have the right to inspect and copy your information,

certain information relating to civil, criminal, or administrative proceedings, and certain

information prohibited by law from disclosure. Any request should be sent in writing to the

contact listed at the end of this Notice. If you wish additional information, you should write

to the contact listed at the end of this Notice.

 

FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO A PAPER COPY OF THIS NOTICE:

You have the right, even if you have agreed to receive notice by email, to get a paper copy

of this Notice. All requests should be in writing and sent to the contact listed at the end of

this Notice.

FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO FILE A COMPLAINT. If you

believe your privacy rights have been violated, you have the right to complain to us by

writing to the contact listed at the end of this Notice. Federal law prohibits retaliation

against you for filing such a complaint. The contact listed at the end of this Notice is also

available to provide you information regarding questions you have or other information

concerning this Notice.

 

THE CONTACT TO WHOM YOU SHOULD ADDRESS YOUR COMPLAINT IS:

Thomas Wolfe, PT, DPT, CSCS

License # 1342296

Telephone Number: 512-964-1844

The effective date of this notice is 08/18/2022.

 

We are authorized to release pertinent medical information to your referring physician.

We are authorized to release medical information to your insurance company regarding coverage for

services performed with the patient.


HIPAA Acknowledgement:

I hereby acknowledge that I have received a copy of the Notice of Privacy Practices as required by HIPAA. I further acknowledge that by typing my name, or e-signing, this is considered a legal binding document. (please type full name below).

*
Acknowledgements, Financial Responsibility, Cancellations Guarantee of Payment / Financial Responsibility / Insurance:

Payment is due at the time of service.

I agree to pay Wolfe Physical Therapy PLLC in full for any outstanding balance that is not covered by the patient/participants insurance. I understand that any outstanding balance is my/our responsibility. I agree to pay the balance within 14 days of receipt of invoice (unless a payment plan has been discussed and agreed upon beforehand).

Cancellations:

I understand that if I am unable to attend a scheduled appointment, I am required to cancel the appointment by email or call Dr. Thomas Wolfe PT, DPT or Dr. Kennedi Henneberger PT, DPT or Dr. Keri Jones PT, DPT or Dr. Nicole Oberdorf PT, DPT, Dr. Madison Ryan Fisher, DPT, Dr. Ellen Jordahl, DPT  24 hours prior to the said appointment; otherwise a fee of $50 late cancellations or No-Shows. This full-rate fee is required because another patient, who needs treatment, could have been scheduled and treated in this time slot.

By signing my name below, I verify that I have read and agree to the information contained in this packet and that the information I have provided is true and accurate. I further acknowledge that by typing my name, or e-signing, this is considered a legal binding document. Patient’s signature (Or, responsible party if the patient is a minor or unable to sign. Please include relationship.) (please type you full name below). *
Payment Policy and Authorizationtion

Payment Policy and Authorization

By signing this consent form, you acknowledge and agree to the following:

If you fail to cancel your appointment at least 24 hours in advance or do not show up for your scheduled appointment, your card on file will be automatically charged a $50 no-show or late cancellation fee.You authorize Wolfe Physical Therapy, PLLC to charge your card on file for the applicable fee in the event of a late cancellation or no-show.

(please type your full name below).
 *
Appointment Reminders

Consent to Receive Appointment Reminders via Text Message

By signing this consent form, you authorize Wolfe Physical Therapy, PLLC to send you appointment reminders, updates, and other relevant notifications via text message to the mobile phone number you have provided.

You understand that message and data rates may apply, and you can opt out of receiving text messages at any time by notifying us directly or following the instructions in the text messages.

By signing below, you consent to receive text messages related to your appointments and other services provided by Wolfe Physical Therapy, PLLC.


(please type your full name below).

 *
Medicare Advance Beneficiary Notice

Medicare does not pay for maintenance therapy once a patient has stopped progression. If he/she wishes to continued treatment then he/she will be require to sign Medicare Form (CMS-R-131-G, ABN) ADVANCE BENEFICIARY NOTICE. At this time, the patient will be responsible for the remaining treatments. I further acknowledge that by typing my name, this is considered a legal binding document. (please type your full name below).


*
Social Media Release (Optional)

Wolfe Physical Therapy Social Media Photo/Video Release:

We may use one of the options listed:

Complete Name, First Name, Nickname, Anonymous

I authorize and grant Wolfe Physical Therapy to take my photos regarding my experiences with them.

I grant Wolfe Physical Therapy to use my photos on Facebook, Instagram and other social media platforms.

I allow Wolfe Physical Therapy to edit, alter, copy or distribute photos for social media advertising and marketing

I agree that the photos belong to Wolfe Physical Therapy

I understand that I will receive no monetary compensation

I further acknowledge that by typing my name, this is considered a legal binding document. (please type your full name below).

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