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Patient Intake Packet - Fischer PT
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Patient Type
Standard Patient
Work Comp/Motor Vehicle Accident Patient
Medicare Patient
Telemedicine Patient
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Name
Your answer
Date
MM
/
DD
/
YYYY
Patient Height
Your answer
Patient Weight
Your answer
How did you hear about Fischer Physical Therapy?
Physician
Friend
Yellow Pages
Newspaper
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Is an attorney involved with this case?
Yes
No
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If Yes, please list attorney name and phone number
Your answer
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