New Patient FormComplete form below and we will contact you to schedule treatment. Consent For Treatment * I consent to and authorize EVOLVED PHYSICAL THERAPY, LLC (EVOLVED PT) to provide care and treatment with physical therapy and related services. I acknowledge that no guarantees have been made to me about the results of treatment. This consent is intended as a waiver of liability for such treatment excepting acts of negligence. Yes Privacy Policy * I have been given the opportunity to view a copy of the Notice of privacy practices at https://www.evolvedptsf.com/privacy. Yes Medicare / Medicaid Policy * Does patient have Medicare / Medicaid? Yes No Cancellation / No Show Policy * I agree to provide at least 24-hour notice when I need to cancel or reschedule an appointment. Cancellation of less than 24 hours or not showing up for a scheduled appointment will likely result in a cancellation / no show fee that is subject to change in dollar amount at a future time. Yes Payment Policy * I acknowledge that all payments for services provided by EVOLVED PT are due at time of service. I understand a credit card may be requested to be kept on file prior to treatment at EVOLVED PT for enforcement of cancellation / no show policy. I authorize EVOLVED PT to charge my credit card for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account. Yes Credit Card To Be Kept On File For enforcement of cancellation / no show policy. American Express Discover / Mastercard / Visa Patient Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date Of Birth * mm/dd/yyyy MM DD YYYY Patient Age * Is patient older than 17 years of age? Yes No Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### How Did You Hear Of EVOLVED PHYSICAL THERAPY? * Word Of Mouth Internet / Google Search Yelp! Doctor Referral N/A What Brought You To EVOLVED PHYSICAL THERAPY? Patient Medical History * Check all that apply. Pacemaker Cancer Diabetes High blood pressure Stroke Dizziness Fainting Seizures Osteoporosis Currently pregnant HIV Hepatitis NONE OF THE ABOVE Does Patient Want Dry Needling Treatment? * Dry needling is a technique where a thin, solid needle is inserted into specific muscles to treat myofascial trigger points, aiming to relieve pain, reduce muscle tightness, and improve movement. Dry needling, while generally safe, can cause minor side effects like soreness, bruising, bleeding, and fatigue, and in rare cases, more serious issues like nerve damage or pneumothorax (collapsed lung). Yes No Would You Like Appointment Reminders? * Text No reminder please Thank you!
