General Patient Information
Date: _________________________
Name: ____________________________________________________________________________
Address: ___________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Phone (Work):___________________ (Cell): ___________________ (Home) ___________________
Date of Birth:______________________
Social Security #:__________________________
Email Address: _____________________________________________________________________
How were you referred?
_______________________________________________________________
Primary Care or Referring Physician?
_____________________________________________________
Occupation: ________________________________________________________________________
Off work because of current episode:
Yes / No Since: ___/___/_____
INSURANCE INFORMATION:
Member ID #____________________________________________________________________
Group #________________________________________________________________________
Insured’s Name and DOB (if Different than patient)______________________________________
Stephanie Leaf P.T, D.P.T
Doctor of Physical Therapy - License # 024593
Specializing in Manual Orthopedics
15 East 10th St. Suite 1C
NY, NY 10003
646-919-0959
HISTORY OF PRESENT COMPLAINT
Describe relevant symptoms: ____________________________________________________
Present since ___/___/_____
Improving / unchanging / worsening
Commenced as a result of: _________________________________ or no apparent reason
What makes it:
Better: ______________________________________________________________________
Worse: ______________________________________________________________________
Previous treatments: ___________________________________________________________
X-Rays: Yes / No
MRI: Yes/No
Results:______________________
MEDICAL HEALTH QUESTIONNAIRE
Circle any of the following symptoms that you have experienced in the past month:
Loss of Appetite
Headaches
Shortness of Breath
Fever
Nausea
Vomiting
Change in Bowel/Bladder
Chills
Swelling
Sweats
Bruising/Bleeding
Weakness
Lightheadedness
Rash
Dizziness
Vertigo
Numbness
Anxiety
Weight loss
Circle any of the following that you have:
Pacemaker
Diabetes
Cancer or history of Malignancy
Osteoporosis
Recent or major surgery: Yes / No
Date: ___/___/_____ Details: ____________________
Accidents: Yes / No
Date: ___/___/_____ Details: ____________________
Unexplained weight loss: Yes / No
Stephanie Leaf P.T, D.P.T
Doctor of Physical Therapy - License # 024593
Specializing in Manual Orthopedics
15 East 10th St. Suite 1C
NY, NY 10003
646-919-0959
PATIENT AGREEMENT FORM
Thank you for electing Stephanie Leaf Physical Therapy. In order to facilitate your treatment I ask that
you read and sign this agreement and authorization.
- A scheduled appointment must be cancelled at least 24 hours in advance, the fee of your
treatment schedules will be due.
- You agree to be responsible for payment of all fees in ful at the time of your appointment,
including copayments.
________________________________
Signature of Patient
_________________
Date
CONSENT FOR MEDICAL TREATMENT
I hereby authorize and request Stephanie Leaf P.T, D.P.T to provide such medical care and administer
procedures and treatments as in the judgment of the New York State licensed physical therapist in
attendance and deemed necessary and advisable.
________________________________
Signature of Patient
Stephanie Leaf P.T, D.P.T
Doctor of Physical Therapy - License # 024593
Specializing in Manual Orthopedics
_________________
Date
15 East 10th St. Suite 1C
NY, NY 10003
646-919-0959
ASSIGNMENT OF BENEFITS TO
STEPHANIE LEAF PHYSICAL THERAPY, PLLC
I ________________ hereby instruct and direct ________________
insurance company to pay by check:
STEPHANIE LEAF PHYSICAL THERAPY
15 EAST 10TH STREET 1C
NEW YORK, NY 10003
646-919-0959
If my current policy prohibits direct payment to the treating therapist, and
sends reimbursement directly to me(the patient) I will mail a check to the
above address in the amount reimbursed.
THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS.
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.
I______________________ authorize the use of my signature below on all
insurance submissions, insurance appeals and complaints on my behalf, and I
understand that I am financially responsible for all charges whether or not
paid by insurance.
Signature of Policy Holder____________________________________
Date______________________________________________________
Stephanie Leaf P.T, D.P.T
Doctor of Physical Therapy - License # 024593
Specializing in Manual Orthopedics
15 East 10th St. Suite 1C
NY, NY 10003
646-919-0959
PRIVACY AUTHORIZATION
This authorization is required by the privacy regulations recently promulgated by the United States
Department of Health and Human Services.
Your protected health information including individually identifiable information, such as names,
dates, phone/fax numbers, email address, demographic data, photographs, x-rays, and study models
may be used or disclosed for the purpose(s) of:




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Lectures/presentations;
Publications;
Research;
Practice Marketing; and/or
Other (specify): ____________________________________
This information will be disclosed by the following people: Stephanie Leaf
The information will be disclosed to the following people/entities: Those listed above.
You have the right to revoke this Authorization at any time in writing. However, your revocation will
not be effective to the extent that this Authorization has been relied on.
The information used or disclosed per this Authorization may be subject to re-disclosure by the
recipient(s), and this, no longer protected by the privacy rules.
______________________________
Patient Signature
______________________________
Witness Signature
______________________________
Patient Name
______________________________
Witness Name
______________________________
Date
______________________________
Date
Stephanie Leaf P.T, D.P.T
Doctor of Physical Therapy - License # 024593
Specializing in Manual Orthopedics
15 East 10th St. Suite 1C
NY, NY 10003
646-919-0959
PRIVACY CONSENT
This form is required by the new patient privacy regulations recently issued by the United States
Department of Health and Human Services. Prior to commencing your physical therapy treatment, you
must review, sign, and date this form.
Your protected health information (i.e., individually identifiable information such as names, dates,
phone/fax numbers, email addresses and demographic data) may be used in connection with your
treatment, payment of your account or health care operations (i.e., performance reviews, certification,
accreditation and licensure).
You have the right to review our office’s privacy notice prior to signing this Consent, a copy of which
was given to you with this Consent.
You have the right to request restrictions on the use of your protected health information. However, we
are not required to, and may not, honor your request.
We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of
the changes and the changes may not be implemented prior to the effective date of the revised notice.
You may revoke this consent at any time in writing. However, such a revocation will not be effective
to the extent that any action has been taken in reliance on this Consent.
Thank you for your cooperation. Please let us know if you have any questions.
______________________________
Patient’s Signature
______________________________
Witness Signature
______________________________
Patient Name
______________________________
Witness Name
______________________________
Date
______________________________
Date
Stephanie Leaf P.T, D.P.T
Doctor of Physical Therapy - License # 024593
Specializing in Manual Orthopedics
15 East 10th St. Suite 1C
NY, NY 10003
646-919-0959