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SOS PHYSIO of Aventura, FL

Patient Intake

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Oficina de Hialeah · cambiar de clínica · English

Registro de paciente nuevo

1. Información del Paciente

Escríbala como mes/día/año, por ejemplo 03/15/1958, o solo los dígitos, 03151958. Su edad se calcula a partir de esto; no es necesario ingresarla dos veces.

Requerido para recibir boletines informativos.

2. Información sobre mi condición

Toda la información es obligatoria.

Importante para pacientes de Medicare: por favor vea el aviso que se le pedirá firmar.

Seguro

Solo el nombre de la compañía: la recepción copiará su tarjeta.

3. Información de pago

Elija una opción.

Tarifas para pago por cuenta propia: Evaluación: $150.00. Visitas de seguimiento: $125.00 cada una. Pagadero al momento del servicio.

4. Información de referencia

Por favor lea y firme

Estos son los mismos documentos que el paquete en papel. Solo se muestran los que aplican a usted.

Firme una sola vez para todo el paquete

Opcional. También puede firmar cada documento por separado a continuación.

Firma del paciente

Esta firma se aplicará a:

  • Formulario de Registro Expreso
  • Acuerdo de Consentimiento Informado y Políticas
  • Declaración de Aviso de Privacidad

Formulario de Registro Expreso

Los datos que usted acaba de darnos.

Ponga sus iniciales en cada casilla.

Política de retraso “15 minutos”

Si llega tarde por más de 15 minutos, deberá reprogramar o esperar la próxima apertura disponible. No hay garantías ya que las aperturas debido a cancelaciones son impredecibles. No permitimos la superposición de citas, ya que esto compromete indebidamente la atención de otro paciente.

Tarifa de Aviso Anticipado de 24 Horas

Si desea cambiar o cancelar una cita, requerimos un aviso con un mínimo de 24 horas de anticipación. Cualquier cosa menos resultará en una tarifa de $50 que se cobrará a su cuenta. Nos cuesta dinero hacer citas disponibles para usted. Ya sea que asista o no, seguimos acumulando los gastos (salarios del personal, alquiler, etc.). No le cobramos el costo real de esa cita, sino una tarifa de $50. NO ganamos dinero con este cargo; es solo para disuadir los cambios de última hora. El aviso anticipado permite que otra persona (que lo necesita) tenga tiempo para reservarla en su lugar. Por favor, sea cortés y responsable. Gracias.

Los copagos se deben al llegar o según el plan de tratamiento

Valoramos y nos centramos primero en los planes de tratamiento de nuestros pacientes, por lo que preferiríamos finalizar todas las finanzas de antemano y centrarnos en su bienestar. Estamos establecidos para cobrar todos los copagos el primer día de su plan de tratamiento designado o en cuotas preautorizadas iguales.

Las ausencias son malas

Si no se presenta a una cita sin previo aviso, se eliminarán todas las citas futuras y se le aplicará una tarifa de $50 a su cuenta. Puede reprogramar citas nuevamente por orden de llegada.

Los teléfonos celulares deben estar APAGADOS o en silencio.

Nos damos cuenta de que pueden surgir emergencias y, por lo tanto, le permitimos llevar su teléfono celular durante su sesión; sin embargo, sea cortés y póngalo en modo silencioso o apáguelo. Gracias.

No se permite que los niños que requieran supervisión asistan a las sesiones con usted.

A menos que su instalación ofrezca servicios de cuidado de niños, no puede traer niños que requieran supervisión con usted a su cita. Si su hijo no requiere supervisión y es capaz de esperar tranquilamente por usted, entonces puede traerlo. Si causa alguna molestia a otros pacientes o miembros del personal, se le puede pedir que finalice su sesión temprano y atienda a su hijo.

Aviso Importante del Gobierno Federal:

“Es ilegal evitar rutinariamente pagar su copago, deducible o coseguro, incluso si su médico lo permite. A menos que complete un formulario de “Dificultad Financiera” y califique para asistencia financiera según los Estándares Federales.

Firma del paciente

Atención Pacientes de Medicare — Importante

SI ACTUALMENTE RECIBE TRATAMIENTOS DE SALUD EN EL HOGAR POR CUALQUIER MOTIVO, DEBE SER DADO DE ALTA DEL CUIDADO DE SALUD EN EL HOGAR ANTES DE QUE PUEDA SER ATENDIDO EN NUESTRA CLÍNICA O MEDICARE NO PAGARÁ SUS VISITAS. SI ESTA INFORMACIÓN SE NOS OCULTA Y MEDICARE RECLAMA NUESTROS PAGOS, USTED SERÁ RESPONSABLE AL 100% DEL PAGO.

Firma del paciente

Cesión de Beneficios

Esta es una cesión directa de mis derechos y beneficios bajo esta póliza.

El pago no excederá mi deuda con el cesionario antes mencionado, y he aceptado pagar, de manera actual, cualquier saldo de dichos cargos por servicios profesionales por encima de este pago de seguro.

Se considerará que una fotocopia de esta Cesión es tan efectiva y válida como el original.

Firma del titular de la póliza

Declaración de Aviso de Privacidad

Este aviso describe cómo puede utilizarse y divulgarse la información médica sobre usted y cómo puede obtener acceso a esta información. Por favor, revíselo detenidamente.

Cómo puede utilizarse su información

Podemos divulgar su información de atención médica a otros profesionales de la salud dentro de nuestra práctica con fines de tratamiento, pago u operaciones de atención médica. Podemos divulgar su información médica a su proveedor de seguro con fines de pago u operaciones de atención médica. Podemos divulgar su información de salud según sea necesario para cumplir con las leyes estatales de compensación laboral. Podemos divulgar su información médica para notificar o ayudar a notificar a un miembro de la familia, u otra persona responsable de su atención, sobre su condición médica o en caso de una emergencia o de su fallecimiento.

Divulgaciones requeridas o permitidas por la ley

Según lo exija la ley, podemos divulgar su información de salud a las autoridades de salud pública para fines relacionados con: la prevención o el control de enfermedades, lesiones o discapacidades, la denuncia de abuso o negligencia infantil, la denuncia de violencia doméstica, la denuncia a la Administración de Alimentos y Medicamentos de problemas con productos y reacciones a medicamentos, y la denuncia de exposición a enfermedades o infecciones. Podemos divulgar su información médica en el curso de cualquier procedimiento administrativo o judicial; a un funcionario encargado de hacer cumplir la ley con fines tales como identificar o localizar a un sospechoso, fugitivo, testigo material o persona desaparecida, cumpliendo con una orden judicial o citación, y otros fines de aplicación de la ley; a médicos forenses o examinadores médicos; a organizaciones involucradas en la obtención, conservación o trasplante de órganos y tejidos; a investigadores que realicen investigaciones que hayan sido aprobadas por una Junta de Revisión Institucional; y para fines militares, de seguridad nacional, de prisioneros y de beneficios gubernamentales. Puede ser necesario divulgar su información médica a personas apropiadas para prevenir o disminuir una amenaza grave e inminente a la salud o seguridad de una persona en particular o del público en general.

Citas, contacto y actividades benéficas

Podemos dejar un mensaje en un dispositivo de contestación automática o a la persona que contesta el teléfono con fines de programación de citas. No se divulgará información de salud personal durante esta grabación o mensaje, que no sea la fecha y hora de su cita programada junto con una solicitud para llamar a nuestra oficina si necesita cancelar o reprogramar su cita. Podemos contactarlo por teléfono, correo o email. Es nuestra práctica participar en eventos benéficos y de marketing para crear conciencia, donaciones de alimentos, regalos, dinero, etc. Durante estos tiempos, podemos enviarle una carta, postal, invitación o llamarlo a su casa para invitarlo a participar en la actividad benéfica. En el caso de que seamos vendidos o fusionados con otra organización, su información/registro de salud pasará a ser propiedad del nuevo propietario.

Sus derechos

Tiene derecho a solicitar restricciones sobre ciertos usos y divulgaciones de su información médica; sin embargo, se le informa que no estamos obligados a aceptar la restricción que solicitó. Tiene derecho a recibir o que se comunique su información de salud a través de un método alternativo, o que se envíe a una ubicación alternativa que no sea el método habitual de comunicación o entrega, previa solicitud. Tiene derecho a inspeccionar y copiar su información médica. Tiene derecho a solicitar que modifiquemos su información de salud protegida; sin embargo, se le informa que no estamos obligados a aceptar la modificación de su información de salud protegida; si se ha denegado su solicitud para modificar su información de salud, se le proporcionará una explicación de los motivos de nuestra denegación e información sobre cómo puede discrepar con la denegación. Tiene derecho a recibir un informe de las divulgaciones de su información de salud protegida realizadas por nosotros. Tiene derecho a una copia en papel de este Aviso de prácticas de privacidad en cualquier momento que lo solicite.

Nuestros deberes, y cómo presentar una queja

Nos reservamos el derecho de modificar este Aviso de prácticas de privacidad en cualquier momento en el futuro, y las nuevas disposiciones entrarán en vigencia para toda la información que mantengamos. Hasta que se realice dicha modificación, estamos obligados por ley a cumplir con este Aviso. Estamos obligados por ley a mantener la privacidad de su información de salud y a proporcionarle un aviso de nuestros deberes legales y prácticas de privacidad con respecto a su información de salud. Si tiene preguntas sobre alguna parte de este aviso o si desea más información sobre sus derechos de privacidad, comuníquese con nosotros llamando a esta oficina al (305) 306-8376. Si nuestro Oficial de Privacidad no está disponible, puede programar una cita para una conferencia personal en persona o por teléfono dentro de los 2 días hábiles. Las quejas sobre sus derechos de privacidad, o cómo hemos manejado su información de salud, deben dirigirse a nuestro Oficial de Privacidad llamando a esta oficina al (305) 306-8376. Si no está satisfecho con la forma en que esta oficina maneja su queja, puede presentar una queja formal a: DHHS, Office of Civil Rights, 200 Independence Avenue, S.W., Room 509F HHH Building, Washington, DC 20201.

Firma del paciente

Información y Consentimiento para la Punción Seca

Información y Consentimiento para la Terapia de Ondas de Choque

Información y Consentimiento para la Terapia PEMF

Su licencia y tarjeta de seguro

Opcional. Si los tiene con usted, la recepción puede fotografiarlos ahora en lugar de copiarlos después.

Licencia de conducir o identificación con foto — frente

Licencia de conducir o identificación con foto — reverso

Tarjeta de seguro — frente

Tarjeta de seguro — reverso

Matvey Gorzhevsky

Matvey Gorzhevsky is licensed accredited Physical therapist in the state of Florida & in Canada. He graduated from the University of Ottawa in 2003.Throughout his career he has owned and operated several medical and physical therapy centers in both Canada & USA. In 2013, he moved to sunny Florida, where he pursued his career in physical therapy. He then, in 2016, opened the first SOS PHYSIO clinic. He specializes primarily in orthopedics. Over the years he has taken numerous continuing education courses particularly in Manual therapy level 1- 3, TMJ specialization, Shirley Sahrmann, McKenzie, Acupuncture, vestibular rehabilitation and a certification in Active Release Techniques (ART). He uses his hands to evaluate the texture, tightness and movement of a joint, muscle, fascia, tendons, ligaments and nerves. Abnormal tissues are treated by combining precisely directed tension with very specific patient movements. This will speed up patient’s recovery process, minimize treatment length, and maximize patient’s benefits. He treats a Varity of orthopedic and neurological conditions such as : low back pain, rotator cuff injuries , meniscus lesions, sciatica, plantar fasciitis, BBPV, TMJ , poor Posture, balance and coordination deficits ( Parkinson, strokes, Ataxia , Cerebral Palsy), dizziness and headaches.

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ARIF SALLA

My name is Arif Salla and I am a South Florida native who graduated from Wheeling Jesuit University in 2018 with my Doctorate in Physical Therapy. I have always had a passion for fitness, wellness, and education. Ienjoy working with patients of all levels and ages and find great satisfaction in not only helping patients recover from their injuries but also inspiring a healthy lifestyle. My main goal as a therapist is to help people realize and obtain their optimal potentials.

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JOSELY G. MANRIQUE

I am a Venezuelan Physical Therapist who came to Miami tocontinue growing professionally. Currently, I am every day in this amazing center to welcoming, comforting and assisting each patient. My main objective is to help the team of therapists and support each of our patients.

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Shreya Soni

My name is Shreya Soni. I am a Licensed Doctor of Physical Therapy. I completed a Bachelor of Physical Therapy from India. Upon graduating I came to the USA and earned a Master’s degree in exercise science and Doctor of physical therapy from California Baptist University and Loma Linda University, respectively. I have extensive experience in musculoskeletal injuries and post-surgical rehabilitation with a focus on Manual therapy. My strong clinical interest is in treating shoulder injuries and surgeries. My goal for all my patients is to help them return to a fully functional lifestyle after an injury.

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IEVA SCIUKAUSKAITE

IEVA SCIUKAUSKAITE has been a licensed Physical Therapist since 2012. She received her bachelor’s degree in Physical Therapy from Lithuanian Sports University in Europe, Lithuania. After obtaining her degree, she practiced as a geriatric and a sport rehabilitation physical therapist for a while. Later Ieva continued her studies in Chicago IL, and became a licensed physical therapist in the US. She participated in various seminars on manual therapy techniques, rehabilitation methods and specific exercises for injuries. Her strong clinical interests are sports injuries and post-surgical treatment. Ieva was a part of the national Lithuanian track and field team as a javelin thrower. On her free time she loves to play tennis and beach volleyball. Ieva is very enthusiastic, receptive to innovations, loves to help patients to recover faster, and always seeking for the maximum results.

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JACKI RENTA

Jacki has been with SOS PHYSIO since it opened in 2016. Jacki has been working in the medical field for over 20 years she has experience in all aspects of Medical office management from front desk to billing. Jacki works closely with the patients and therapists to make sure patients have a clear understanding of their treatment plans and insurance coverage.

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Carlos A Castillo

My name is Carlos A Castillo; I grew up as the smaller of two brothers in the west side of Cuba. When I was growing up, I would watch every soccer game on TV, before going outside and toss the soccer ball around. I’ve loved it ever since. I’ve always love to help people that needed my assistance, reason why when I came to America in 2013, I decided to join the healthcare field following the steps of my wife. Once I decided for Physical Therapy, I worked as a PT aide for two years while I was getting my degree. Now, I have the opportunity to apply all my knowledge to my patients, and help them with no less than one hundred percent of love and professionalism. I want patients to look and me and say “thanks to you, I am now feeling better”.

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Jorge Bazante

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Isnel Hernandez

Isnel Hernandez has been with SOS PHYSIO team for over a year now. I love to be part of a team that’s full of energy and ready to help others recover from pain, trauma, or surgery anywhere in the body. I always knew I wanted to involved in the health field because I love helping others, I became a Physical Therapist Assistant with a passion continue studying and become a doctor of physical therapy one day.

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KARLA SANABRIA

Karla has a degree in Physical Therapist Assistant, Graduated from Miami Dade College since July 27, 2011, remarkable knowledge of physical therapy principles, theory, methods and their application in a home health and clinical environment. She has the ability to understand the role of therapy in the context of the patient’s age, total needs perspective and environment . Uncommon ability to recognize when standard patient protocols or treatment plans need modification to meet individual patient needs.

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STEVEN ABOSAID

My name is Steven Abosaid and I am from South Florida. I graduated from the Praxis institute PTA program in 2021. I have always had a passion for sports and working out. I first began my interest with Physical Therapy when I was involved with football and also being involved with fitness. I love to help others to live a better life style

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DEREK JEREZ​

I play guitar, I love Marvel movies, and I get to be part of something amazing: helping people get better. I chose physical therapy because I’ve seen the impact it has on people’s lives. My own grandma went from an injured knee back to hardening thanks to the hard work put in through Physical Therapy. I wanted to be part of that life changing process and help others. I’m new in the field but I’ve learned so much and I want to use that knowledge to help people get back to feeling great and living their best life.

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Nicole Duque

Hi my name is Nicole Duque I have been in the health care field for more 5 years. I love helping people. My goal at SOS PHYSIO is to make you feel happy and at home. I am here to answer any questions you may have.

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REYNA URIARTE

HI, MY NAME IS REYNA IM A RECEPCIONIST AT SOS PHYSIO AND IT’S BEEN A PLEASURE WORKING WITH THIS COMPANY THAT IS VERY ENGANGED TO HELP YOU. IM HERE TO GIVE MY BEST TO YOU AND MAKE SURE YOU FEEL AT HOME. I’LL ENJOY HELPING YOU WITH YOUR NEEDS AT THE FRONT DESK WITH ANY QUESTIONS OR SCHEDULING CONCERNS.

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Angela Rodriguez

Angela Rodriguez has 11 years of experience as a medical assistant as well as customer service. I love to help patients and be a part of their healing journey.

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Kristy Serrano

Kristy Serrano has 15 passionate years of helping others. As a registered nurse, she has been able to combine this passion with her desire to make a difference. Kristy obtained her RN certification after completing a 3 year nursing program at FIU. She went on to specialize in Cardiology, and she has a natural when it comes to taking care of those in need. Kristy loves getting to know her patients and taking part in the development and health of each individual. When not at work, Kristy enjoys spending time with her 2 kids & husband & her two rescue dogs!

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Oscar Hernandez

I’m a skilled and compassionate physical therapist who is dedicated to helping patients recover and regain their mobility. I love my career and helping patients is my reward.
In the personal aspect, I enjoy reading books, working out and riding motorcycle.

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Alexander Carillo

Alexander is a licensed PT in Florida. He graduated from the University of St. Augustine for Health Sciences in 2020. He is passionate about sports and orthopedics. He performs instrument assisted soft tissue mobilization, KT taping, manual therapy techniques including mobilizations and thrusts. He is licensed in dry needling which is a treatment that uses Dry Needling needles to target specific structures. This intervention is performed with or without electricity. Alex has experience working with a variety of populations, diagnosis, and age groups.

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Melissa Duran

Melissa Duran is a dedicated Doctor of Physical Therapy who graduated from the University of St. Augustine for Health Sciences in 2022. With a passion for promoting health and wellness, she believes in the fundamental principle that “motion is lotion”—that our bodies are designed to move and thrive through physical activity. In 2024, Melissa enhanced her skills by obtaining certification in dry needling, a technique that complements her holistic approach to physical therapy. Her mission is to empower patients to achieve their optimal health through tailored treatment plans that emphasize movement and rehabilitation. Driven by a commitment to continuous improvement, Melissa strives to be better each day, both personally and professionally. She is dedicated to fostering a supportive environment where her patients feel motivated and equipped to reach their health goals.

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Marilyn Eustache

Marilyn Eustache, MS, OTR/L is a licensed Occupational Therapist dedicated to helping patients restore function, independence, and confidence through personalized, evidence-based care. She specializes in treating injuries, post-surgical conditions, and functional limitations that impact daily living.

Marilyn Eustache, MS, OTR/L, is a licensed Occupational Therapist with over a decade of experience across pediatrics, outpatient care, neural orthopedics, geriatrics, and acute hospital settings. A graduate of Florida International University, where she earned her Master of Science in Occupational Therapy, Marilyn blends evidence-based practice with a holistic, inclusive approach that empowers clients to achieve meaningful functional outcomes. Her expertise spans clinical leadership, sensory integration, orthopedic rehabilitation, and family-centered care. As a certified yoga instructor, she integrates mind-body techniques to support balance, mobility, and overall wellness.

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Alex Peskoe

I enjoy and love this team, which has full energy. I enjoy making sure patients are taken care of and recover from any and all injuries. I became a PTA after training clients in the gym to impact patients in a more fulfilling way.

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Alejandro Reyes

I am deeply passionate about my career, and providing the greatest level of patient care. I love animals, coffee, outdoor sports, exercise, and spending time with family. I also love food… I am willing to try anything once. I specialize in exercise and massage therapy, and believe in empowering my patients to achieve their maximum potential.

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Derek Jerez

I play guitar, I love Marvel movies, and I get to be part of something amazing: helping people get better. I chose physical therapy because I’ve seen the impact it has on people’s lives. My own grandma went from an injured knee back to hardening thanks to the hard work put in through Physical Therapy. I wanted to be part of that life changing process and help others. I’m new in the field but I’ve learned so much and I want to use that knowledge to help people get back to feeling great and living their best life.

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Pablina Barberena

She is  friendly, organized, and customer-focused professional with strong communication skills. She has decades of experience in customer service and administrative support. Her goal is to ease patients clerically in their healing.

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Roxangel Mota

Hello, my name is Roxangel Mota, but everyone calls me Roxy. I’ve been working in the healthcare field for almost 4 years, and I have over 7 years of experience in customer service. I love helping people. My goal at SOS PHYSIO is to provide the best possible help and assistance, and I’m here to answer any questions you may have.

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Dana Davila

Dana has been a Physical Therapist Assistant since 2020. Growing up playing sports, she learned early on how important movement and proper recovery are. She is excited to be part of a team that is focused on improving patients’ lives, helping them heal, regain strength, and return to the activities they love.

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Dayanna Zeas

Dayanna is a warm and reassuring first point of contact at the clinic. She greets patients with kindness and enjoys making everyone feel welcomed and cared for from the moment they walk in. Her goal is to provide everyone with top quality customer service and to make their journey with physical therapy a positive experience.

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Erika Estrella

Hi, my name is Erika! I have over 5 years of medical front desk experience providing professional and compassionate support to patients. I take pride in creating a welcoming experience for every patient, while remaining attentive to their needs and ensuring they feel heard and cared for.

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Marys Guerra

I am a dedicated and compassionate Physical Therapist Assistant passionate about helping patients regain their mobility, independence, and quality of life. I am committed to providing personalized, respectful care while adapting each treatment session to the individual needs of my patients. I strive to create a positive and motivating environment while working collaboratively with the healthcare team to achieve the best possible outcomes.

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Joseline Jacobs

My name is Joseline Jacobs, Born in Lima, Peru, I moved to Boston at the age of 18 and later relocated to Florida. I have extensive experience in medical administration and customer service, along with an Associate degree in Massage Therapy. I am a dedicated, compassionate, and hardworking professional who enjoys helping others and continuously growing both personally and professionally.

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Pedro Brito

My name is Pedro Brito. I graduated form Miami dade college and I have been a PTA for 3 years. I love working in a team that is passionate, dedicated and focused on having the best patient care possible.

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Oscar Espinosa

Oscar Espinosa, PT, DPT, earned both his undergraduate degree in Physical Education and his Doctorate in Physical Therapy from Florida International University. He is passionate about providing individualized, evidence-based care to patients with a wide range of orthopedic and neurological conditions.

With extensive experience treating diverse patient populations, Oscar takes pride in guiding each patient through recovery and helping them achieve their goals. His background in martial arts and Olympic weightlifting, along with his own successful return to these activities following physical therapy for meniscal surgery, gives him a personal understanding of the rehabilitation process and the importance of returning to the activities you love.

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Dianelys Perez

Hi, my name is Dianelys Perez. With over 5 years of experience in healthcare, I’m passionate about providing friendly, compassionate, and high-quality customer service. My goal is to help every patient feel welcomed, supported, and cared for throughout their physical therapy journey. I’m excited to be part of a team dedicated to making a positive difference in every patient’s experience.

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Anthony Cosenzo

Tony is from Wilmington Delware where he graduated form Number 2 ranked PTA Program the United States in 2010. Patient treatment progression has been extended to 4 States- Delaware, Pennsylvania ,New Jersey and Florida at over 60 locations. Tony is Certified in Instrument-Assisted Soft Tissue Mobilization, Myofascial Cupping, Kinesiology taping, blood flow restriction therapy.

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