INTAKE FORMS

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Intake Forms

Please fill out the following information for your intake and release forms

PERSONAL INFORMATION

Please type your Last name.
Please type your First name.
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Please enter a valid phone number
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Please enter a valid phone number



EMPLOYMENT

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Please enter a valid phone number

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EMERGENCY CONTACT

Please type name.
Please enter a valid emergency phone
Please type your relationship.



HOW DID YOU HEAR ABOUT US?

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MINOR RELEASE

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Please type name.
Please type your relationship.
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PATIENT QUESTIONNAIRE

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MEDICARE PATIENTS ONLY

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PATIENT MEDICAL HISTORY

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I certify, that the above information is correct. I authorize this clinic to bill my insurance company directly for the covered portion of charges, and I authorize payment of benefits directly to this clinic. I authorize this clinic to release medical or other information necessary to process this claim. I understand, that I am ultimately responsible for medical charges, and I agree to pay my deductible, my co-insurance or co-payment, and any charges not reimbursed by my insurance carrier. I understand, that some insurance companies require medical or administrative pre-authorization for treatment, or have reimbursement limits on physical therapy treatments. I understand I am responsible for knowing and meeting the requirements of my insurance plan.

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Please type your relationship.

INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

Your Responsibility to Minimize Your Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, our staff, and other patients) safer from exposure, sickness and possible death.

  • You will only keep your in-person appointment if you are symptom-free.
  • You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment.
  • You will wait in your car or outside [or in a designated safer waiting area] until no earlier than 5 minutes before our appointment time.
  • You will wash your hands or use alcohol-based hand sanitizer when you enter the building.
  • You will adhere to the safe distancing precautions we have set up in the waiting room and testing/therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.
  • You will wear a mask in all areas of the office (Staff members will too).
  • You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) staff.
  • You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands.
  • If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols.
  • If a resident of your home tests positive for the infection, you will immediately let us know.

Our Commitment to Minimize Exposure Our practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office.

If You or I Are Sick You understand that our office is committed to keeping you, our staff, and other patients] safe from the spread of this virus. If you show up for an appointment, and our staff members believe that you have a fever or other symptoms, or believe you have been exposed, we will have to require you to reschedule your appointment.

If anyone of our staff members tests positive for the coronavirus, we will notify you so that you can take appropriate precautions.

Your signature below shows that you agree to these terms and conditions.
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Miracle Physical Therapy and Massage Center - Warren
3272 E. 12 Mile Rd. #106
Warren, MI 48092
Phone : 586-920-2596
Fax : 586-576-7298

Miracle Physical Therapy and Massage Center - Farmington Hills
30500 Northwestern Hwy. Ste. 316C
Farmington Hills, MI 48334
Phone : 248-539-8781
Fax : 248-539-8940

Developed By: Grinblat Meida, LLC

Miracle Physical Therapy and Massage Center Inc.

All Right Reserved © 2020