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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