Intake | Clearwater Physical Therapy

This field is for validation purposes and should be left unchanged.

Please complete this form prior to your first appointment.

Name*

First Last

Date of Birth*

Home Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Marital Status

Email*

Date of Injury

Chief Complaint*

Emergency Contact*

First Last

Relationship

Emergency Contact Phone*

Referring Physician

Physician Phone

How did you hear about us?*

Insurance Information

Insurance Provider

ID Number

Group Number

Provider Eligibility/Benefits Phone Number

Is the Patient the guarantor of the account?

Yes

No

Who is the guarantor?

Phone

Guarantor Address

Street Address City State / Province / Region ZIP / Postal Code Country

I authorize Clearwater Therapeutics to release my medical information in full or in part to: (Name/Relationship)

Cancellation & Late Arrival Policy*

We appreciate that you’ve chosen us for your care. To provide the best service possible to our clients we have implemented the following policies.

1. Cancellation Policy

We respectfully ask that you provide us with a 24 hour notice of any schedule changes or cancellation requests. Please understand that when you cancel or miss your appointment without providing a 24 hour notice we are often unable to fill that appointment time. This is an inconvenience to your provider and also means others may miss the chance to receive care. For this reason, you will be charged 50% of the average service fee for the first missed appointment and 100% of the average service fee for each session after that. We also reserve the right to require a credit card number to be given to book future appointments so that appropriate fees may be charged if a late cancellation does occur.

We understand that emergencies can arise and illnesses do occur at inopportune times. If you have a fever, a known infection, or have experienced vomiting or diarrhea within 24 hours prior to your appointment time, we request that you cancel your session. Inclement weather may also result in the need for late cancellations. We will do our best to give advance notice if we are closing or need to cancel due to bad weather and we ask you to do the same. Please do not risk your own safety trying to make your appointment. Late cancellation due to emergency, illness, or inclement weather will generally not result in any missed session charges, but this is determined on a case-by-case basis.

2. Late Arrival Policy

We request that you arrive 5-10 minutes prior to your appointment time to allow time to fill out any required paperwork as well as answer any intake questions your provider may have. We understand that issues can arise that may cause you to be late for your appointment. However, we ask that you call to inform us if this ever occurs so we can do our best to accommodate you. Appointment times are reserved for each client, so oftentimes we cannot exceed that reserved time without making the next client late. For this reason, arriving after your appointment time may result in loss of time from your massage so that your session ends at the scheduled time. Full service fees will be charged even when sessions are shortened due to late arrival. In return we will do our best to be on time, and if we are unable to do so we will add time to your session to make up for our late arrival or adjust the service charge accordingly.

By selecting “I accept”, you agree to abide by these policies.

I accept

Signature*

By my signature, I acknowledge that I have read, understand, and agree to all of the policies and procedures of as defined in the this digital form. I affirm that I have answered all questions truthfully and to the best of my ability.

Insurance Information

Medical History