Patient Intake

Oct 29, 2026

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Hollywood office · change clinic · Español

New patient registration

1. Patient Info

Last Name *

First Name *

Date of Birth *

Type it as month/day/year, for example 03/15/1958 — or just the digits, 03151958. Your age is worked out from this — no need to enter it twice.

Sex *

Street Address *

City *

State *

ZIP *

Home Phone

Cellular *

Email Address *

Required in order to receive newsletters.

I do not have an email address

Occupation

Emergency Contact Person

Emergency Contact Phone #

Marital status

Work Status

2. My Condition Info

All info required.

My injury/ailment is related to… *

Date of accident

Date of injury *

Employer Name *

Employer Phone #

Your company HR person name

Claim number *

Insurance adjustor name

Insurance adjustor PH# *

What do you think may have caused it?

I have already had surgery

Surgery — when and what type?

I have had physical therapy before

Physical therapy — when and where?

I am receiving, or have received, home health care

Important for Medicare patients — please see the notice you will be asked to sign.

Are you still receiving it?

Other care you are receiving (optional)

Insurance

Insurance company name *

Just the company name — the front desk will copy your card.

3. Payment Info

Choose one.

How will this visit be paid for? *

Self-pay fee schedule: Evaluation: $150.00. Follow-up visits: $125.00 each. Payable at the time of service.

Are you the policyholder on this insurance? *

4. Referral Info

How did you hear about us?

Give details

Referring Physician/Person’s Name

Referrer — City

Referrer — State

Referrer — Phone #

Please read and sign

These are the same documents as the paper packet. Only the ones that apply to you are shown.

Sign once for the whole packet

You may skip this. If you sign here, tick the box marked with a red * so the signature applies to every document listed. Or sign each document separately below.

Please sign with your finger

Patient signature

This signature will be applied to:

Express Registration Form
Attention Medicare Patients — Important
Assignment of Benefits
Informed Consent and Policies Agreement
Statement of Privacy Notice
Dry Needling Information & Consent
Shockwave Therapy Information & Consent
PEMF Therapy Information & Consent

Express Registration Form

The details you have just given us.

Initial every box.

Initial

Late Policy “15-minutes”

Being late by more than 15 minutes will require you to either reschedule or wait for the next available opening. There are no guarantees since openings due to cancellations are unpredictable. We do not allow appointment overlap because this undeservedly compromises the care of another patient.

Initial

24-Hour Advance Notice Fee

If you wish to change or cancel an appointment we require a minimum 24-hour advance notice. Anything less will result in a $50 fee charged to your account. It costs us money to make appointments available to you. Whether you attend or not we still accrue the expenses (for staff wages, rent, etc.). We don’t charge you the actual cost for that appointment but rather a mere $50 fee. We do NOT make money with this charge; it’s only to act as a deterrent from making last minute changes. Advance notice allows someone else (who needs it) time to reserve it in place of you. Please be courteous and responsible. Thank you.

Initial

Co pays are due upon arrival or as per treatment plan

We value and focus on our patient’s treatment plans first, therefore would prefer to finalize all finances before hand and focus on your well being. We are set to collect all co pays on the 1st day of your designated treatment plan or equal preauthorized installments.

Initial

No-shows are bad

If you fail to show for an appointment without notice all future appointments will be removed and a $50 fee assessed to your account. You may re-schedule appointments again on a “first come, first serve basis”.

Initial

Cell phones must be shut OFF or silent.

We realize emergencies may arise and therefore allow you to carry your cell phone during your session, how-ever, please be courteous and set to silent mode or turn off. Thank you.

Initial

Children requiring supervision are NOT allowed to attend sessions with you.

Unless your facility offers child care services, you may not bring children who require supervision with you to your appointment. If your child does not require supervision and is capable of waiting for you quietly then you may bring them. If any disturbance is caused to other patients or staff members you may be asked to terminate your session early and attend to your child.

Initial

Important Notice from the Federal Government:

“It is unlawful to routinely avoid paying your co pay, deductible or coinsurance payments . . . even if your doctor allows it. Unless you complete a “Financial Hardship” form and qualify for financial assistance under Federal Standards.

I have read and agree to all the policies on this form.

Please sign with your finger

Patient signature

Attention Medicare Patients — Important

IF YOU ARE CURRENTLY RECEIVING HOME HEALTH TREATMENTS FOR ANY REASON YOU MUST BE DISCHARGED FROM HOME HEALTH BEFORE YOU CAN BE SEEN IN OUR CLINIC OR MEDICARE WILL NOT PAY FOR YOUR VISITS. IF THIS INFORMATION IS WITHHELD FROM US AND MEDICARE RECOUPS OUR PAYMENTS YOU WILL BE 100% RESPONSIBLE FOR PAYMENT.

Please sign with your finger

Patient signature

Assignment of Benefits

This is a direct assignment of my rights and benefits under this policy.

This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.

A photocopy of this Assignment shall be considered as effective and valid as the original.

I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits. I authorize the use of this signature on all insurance submissions. I authorize the “Healthcare Provider” named above to deposit checks made in my name. I authorize the “Healthcare Provider” named above to initiate a complaint to the Insurance Commissioner for any reason on my behalf. I understand that I am financially responsible for all charges whether or not paid by insurance.

Please sign with your finger

Signature of policyholder

Informed Consent and Policies Agreement

Medical Necessity

All treatments must be justified and medically necessary in order for us to treat and bill your insurance. Some of the factors that determine whether or not treatment is medically necessary are: does your condition interfere with the quality of your life; does your condition interfere with your ability to perform work or daily activities; are you motivated and able to participate in your treatment program and follow home and self-care instruction; is there potential for your condition to improve and/or resolve, and if not, is there potential for your function or ability to perform daily activities to improve through modified movement, assistive devices, etc.; are there specific goals set that are measureable and track-able.

Results

The purpose of physical/occupational therapy is to maximize your body’s own healing potential through natural means and promote your ability to perform daily, work, and leisure and sports activities through increased strength, flexibility, agility, and movement strategies. It is not possible to predict the results or outcomes of treatment. Sometimes benefits are realized immediately and sometimes it’s more gradual over time.

Insurance Patients

It is your responsibility to know your benefit and insurance coverage for physical therapy services, including any maximums or exclusions. You are responsible for all charges whether paid by insurance or not. Any balances that exceed 30 days may incur fees and collection costs.

Medicare Patients

If you do NOT have supplemental insurance, you will be responsible for the twenty percent (20%) co-insurance portion not paid by Medicare as well as any deductible amounts not yet met. It is your responsibility to keep track of therapy cost totals for the purpose of not exceeding the Therapy Cap (unless your diagnosis is exempt from the Cap).

Minors and Parents

If patient is a minor (under 16 years of age), the parent or legal guardian is responsible for all charges and decisions made by the minor. We do not assume any liability for the minor while on premises or not, and it is the responsibility of the parent or guardian to supervise the minor before, during and after treatments.

Informed Consent

By signing below, the patient gives the therapist permission to the evaluation and treatment. It is your right to accept or refuse any treatment offered. There are no guarantees made as to the results that may be obtained from our treatment(s). If you have any questions about your care, be sure to ask the therapist. It is up to patient/caretaker to inform the therapist/staff about any health problems or allergies patient may have. Patient/caretaker must also tell the therapist/staff about drugs or medications being taken as well as any medical conditions and/or surgeries. Please discuss any questions or problems with the therapist before signing this statement of understanding and consent for care.

Patient Declaration

The therapist has explained to me the type of treatments ideal for my condition and the benefits of therapy, along with the risk of NOT receiving treatment. I have been given an opportunity to ask questions, and all my questions have been answered to my satisfaction. I confirm that I have read and fully understand this consent and policies form. I have read and understand the foregoing explanation of rehabilitation/therapy care given to me. I hereby give my consent for the therapist to render treatments to me.

I have read and understand this consent and policies form, and I give my consent for the therapist to render treatment to me.

Please sign with your finger

Patient signature

Statement of Privacy Notice

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

How your information may be used

We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. We may disclose your health information to your insurance provider for the purpose of payment or health care operations. We may disclose your health information as necessary to comply with State Workers’ Compensation Laws. We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.

Disclosures required or permitted by law

As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure. We may disclose your health information in the course of any administrative or judicial proceeding; to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes; to coroners or medical examiners; to organizations involved in procuring, banking, or transplanting organs and tissues; to researchers conducting research that has been approved by an Institutional Review Board; and for military, national security, prisoner and government benefits purposes. It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

Appointments, contact and charitable activities

We may leave a message on an automated answering device or person answering the phone for the purposes of scheduling appointments. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment. We may contact you by phone, mail, or email. It is our practice to participate in charitable and marketing events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation or call your home to invite you to participate in the charitable activity. In the event that we are sold or merged with another organization, your health information/record will become the property of the new owner.

Your rights

You have the right to request restrictions on certain uses and disclosures of your health information; please be advised, however, that we are not required to agree to the restriction that you requested. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. You have the right to inspect and copy your health information. You have a right to request that we amend your protected health information; please be advised, however, that we are not required to agree to amend your protected health information — if your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by us. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Our duties, and how to complain

We reserve the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, we are required by law to comply with this Notice. We are required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact us by calling this office at (305) 306-8376. If our Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. Complaints about your Privacy rights, or how we have handled your health information should be directed to our Privacy Officer by calling this office at (305) 306-8376. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to: DHHS, Office of Civil Rights, 200 Independence Avenue, S.W., Room 509F HHH Building, Washington, DC 20201.

I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide the company above with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.

Please sign with your finger

Patient signature

Dry Needling Information & Consent

I am being offered dry needling and wish to consent to it.

Please be advised that on rare occasions there may be:

Swelling, pain, discomfort, bruising, skin erythema. These are normal body responses during the inflammatory stage of healing. Please be advised that these symptoms may occur but everyone’s response to therapy will be different. If you do notice any of these symptoms please mention it to your therapist.

What is Dry Needling?

Dry needling is a form of therapy in which fine needles are inserted into myofascial trigger points (painful knots in muscles), tendons, ligaments, or near nerves in order to stimulate a healing response in painful musculoskeletal conditions. Dry needling IS NOT acupuncture or Oriental Medicine; that is, it does not have the purpose of altering flow of energy (“Qi” pronounced chee) along traditional Chinese Meridians for the treatment of diseases. In fact, dry needling is a modern, science-based intervention for the treatment of pain and dysfunction in musculoskeletal conditions such as neck pain, shoulder impingement, tennis elbow, carpal tunnel syndrome, headaches, knee pain, shin splints, plantar fasciitis, and low back pain.

Is Dry Needling Safe? Single-use, disposable needles ARE used in this clinic.

Drowsiness, tiredness, and/or dizziness may occur after treatment in a small number of patients (1-3%). If this occurs, you are advised not to drive and to have a driver pick you up. Minor bleeding or bruising can occur after treatment (15-20% of patients) and is considered NORMAL. Temporary pain occurs during dry needling in 60-70% of treatments. Existing symptoms can get worse after treatments (< 3% of patients), however, this is not necessarily a “bad” sign. Fainting can occur in certain patients (0.3%), particularly at the first treatment session when needling of the head/neck is performed. Dry needling is very safe; HOWEVER, serious side effects can occur in less than 1 per 10,000 (< 0.01%) treatments.

Cost

Dry needling package cost is $360.00 for a package of 4 sessions. Single sessions can not be purchased. Dry needling is not covered by insurance and is considered an elective/self-pay treatment.

I have read and understand the information above, including the risks and the cost, and I consent to dry needling.

Please sign with your finger

Patient signature