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PATIENT INFORMATION FORM - SOUTHPOINTE

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Allergies
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Allergic Reactions:
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INSURANCE INFORMATION


INSURANCE INFORMATION

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Was this an Auto Accident?*
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Was this Work Related?*
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Is this a legal case?*
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Have you had Physical Therapy treatment this year?*
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Have you had a Chiropractor treatment this year?
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By checking the following boxes and signing at the bottom of the form, I hereby consent to the following:


By checking the following boxes and signing at the bottom of the form, I hereby consent to the following:

CONSENT FOR TREATMENT
ASSIGNMENT OF BENEFITS/RELEASE OF INFORMATION
PAYMENT POLICY

HABILITY OPT-IN SHEET


HABILITY OPT-IN SHEET

Great news patients!
We have recently acquired a new system that allows you to contact your Physical Therapist as needed by either phone, email or text. We will not contact you regarding your billing, co-pays or such issues through email or text.
This service is to make sure if you have questions regarding your care, that they can be addressed as soon as possible. Selections can be changed at any time, too. Simply select your preferred method of contact below, initial next to it, and we'll handle the rest for you!
Talk soon!
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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