L&I / Worker's Comp Intake Form
This is the Intake Form for a patient who has been injured on the job, and who is relying on workers compensation insurance to pay for the treatment.
Patient Information
First Name *
Please type your first name
Your answer
Last Name *
Please type your last name
Your answer
Date of Birth *
Please use the format MM/DD/YYYY
Your answer
Email
We will not contact you through email for any reason other than to send you our routine satisfaction survey
Your answer
Address *
Example: 12345 45th St. NW
Your answer
Apartment # / Suite #
* If applicable
Your answer
City *
Full Name
Your answer
State *
Your answer
Zip Code *
5 digits
Your answer
Home Phone *
123-456-7890
Your answer
Cell Phone *
123-456-7890
Work Phone
123-456-7890
How did you find us? *
Referring Provider: Name and Phone *
If you were not referred, please put 'none'.
Your answer
Have you had massage for this condition before coming to us?
Have you had massage in the last two years?
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