Skagit_Patient

Intake
First Name
MI
Last Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Apt. #

CityState / Province

Postal / Zip Code
Cell phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Parent Name (if patient is a minor)
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Insurance/Claim Insurance
Primary Insurance
ID#
Secondary Insurance
ID#
L&I Claim # (if applicable)
Worker's Comp/Self Ins Claim #
Date of injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Claim Managers Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Skagit Hand Therapy HIPPA Privacy Acknowledgment
FINANCIAL AGREEMENT/INFO RELEASE: I AM FINANCIALLY RESPONSIBLE FOR THE COSTS OF MY TREATMENT and agree to the policies outlined in "Responsibility for Payment". I AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY to Skagit Hand Therapy. I AUTHORIZE RELEASE OF ANY PERSONAL OR HEALTH INFORMATION
necessary to process insurance claims or to provide and coordinate my treatment. I UNDERSTAND THERE IS A $50 CHARGE, PAYABLE BY ME, for appointments cancelled within 24 hours, or for no show appointments.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical History
Patient Name
Referring Physician
Date of Next Dr Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Care Physician
PCP PracticeLocation
WHEN did your condition start
HOW did your injury occur or your condition begin
Location of Injury?
Are you right or left handed?
Because of your problem, what specific activities are you having difficulty with?
What are your personal goals you hope to achieve from therapy?
What makes it better?
What makes it worse?
Have you had prior physicaloccupational therapy for this condition?
What do or did you do for a living?
How many hours do (or did) you work in a typical week?
If you have retired or stopped working, when?
How would you describe your work duties?
Please list prescriptions overthecounter medications or nutritional supplements that you take or attach a list
PLEASE LIST ANY KNOWN ALLERGIES
Do you consume alcohol If so how many drinks per week
Do you use any nonprescription substances? ie tobacco marijuana vaping opiates etc? If so what type and how much per week?
Are you now or have you ever had any of the following conditions? (CHECK all that apply)
Other
Describe your general health (check one)
Please list any surgeries youve had with approximate dates OR any other health issues not addressed above
Should be Empty:

Intake

Emergency Contact

Medical Insurance/Claim Insurance

Skagit Hand Therapy HIPPA Privacy Acknowledgment

Medical History