NEW PATIENT REGISTRATION FORM - Covenant Health
Covenant Therapy Centers – New Patient Sticker here
Patient Information
Name _________________________________________________________ SS#_____________________________
LAST FIRST MIDDLE
Birthdate _________________________ Marital Status ___________________ Gender_______________________
Address _________________________________________ City_______________ State ______ Zip__________
Home Phone_______________________________________ Cell Phone___________________________________
Work Phone _______________________________________ Email Address ________________________________
Employment ( Full-time ( Part-time ( Unemployed ( Self Employed ( Retired (date) ___________
Employer _________________________________________________________________________________________
Address __________________________________________ City_______________ State ______ Zip__________
Guarantor* (Name of Insured if different than patient) * If same as patient, please skip this section
Name__________________________________________________ Relationship to patient_____________________
LAST FIRST MIDDLE
Birthdate ____________________ Home Phone ________________________ SS# __________________________
Employer ________________________________________________________________________________________
Physician / Emergency Contact
Referring Physician _______________________________________________________________________________
Primary Care / Family Physician _____________________________________________________________________
Complaint/Diagnosis ______________________________________________ Onset Date _____________________
Emergency Contact Name __________________________________________ Relationship to Patient ____________
LAST FIRST MIDDLE
Home Phone _______________________________ Work Phone _______________________________________
Covenant Therapy Centers – Health Information Sticker here
Past Medical History
Please check YES or NO if you presently have or have ever been diagnosed with any of the following:
| |YES |NO |
|Are you currently receiving any treatment from a Home Health Agency? | | |
|Do you receive Dialysis? | | |
|Has the Dept of VA authorized and agreed to pay for your care at this facility? | | |
|Do you receive Black Lung Benefits | | |
|Are your services to be paid by a government research program? | | |
|Have you had a kidney transplant? | | |
Information About Your Injury/Pain
Is this due to an accident? ( Yes ( ( Auto ( Work-related ( Other )
( No* *If no, please skip this section
Accident Date and Time ___________________________________________ State the Accident Occurred _________
Auto Insurance Company____________________________________________ Phone __________________________
Auto Insurance Address _____________________________ City ______________ State ______ Zip __________
Case Manager/Adjustor Name _____________________________________ Phone ___________________________
|Sharing your information |
|In the event our office needs to contact you regarding your appointment, health information, billing, etc.: |
|I give permission to be contacted by phone and for messages to be left at this number |
|( Yes ( ( Cell ( Home ( Work ) ( No |
|I give permission to have letters, documents and postcards to my home and/or email address |
|( Yes ( No |
Acknowledgement of Privacy – Open Gym Atmosphere:
I understand that my treatment may be provided in an open gym atmosphere and agree to request private treatment or conference area if needed.
Witness: ______________________________ Signed: ________________________________________
(Patient or Representative)
Date: _________________________________ By: ____________________________________________
Time: ___________________________ am / pm Relationship to patient: ________________________
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