New Patient Questionnaire s3

NEW PATIENT QUESTIONNAIRE

Patient Name ______Phone ______

Mailing Address ______City, State, Zip______Email:______

Street Address (if different than above) ______TX Drivers License ______

County of Residence ______DOB ______Social Security #:______

Current Employer ______Occupation ______Phone ______

In case of emergency, notify: ______Phone:______

Primary Subscriber: ______DOB: ______

Subscribers Current Employer: ______Relationship to Patient: ______

If this is a WORKERS COMPENSATION injury, complete this portion:

Employer at time of injury ______Phone______

Date of Injury______Area to be treated______

If NOT work related, complete this portion:

IS your referral to our office related to a SPECIFIC INJURY OR ACCIDENT? ______

If YES, date of injury or accident: ______

Brief description of injury/accident: ______

If a minor, name of presenting PARENT/GUARDIAN: ______Daytime Phone ______

Name of Guarantor*:______*(Please note: RRR will NOT be a party to 3rd party custodial agreements, i.e., divorce decrees. We will require payment from the presenting parent/guardian).

Address of Guarantor: ______

Social Security #______Texas Drivers #______DOB: ______

Please read BEFORE SIGNING: I hereby accept full responsibility for any and all charges not covered or reimbursed by my insurance carrier or any other third party payer to Round Rock REHAB, regardless of reason. I AGREE AND UNDERSTAND that I am fully responsible for, and will pay, all amounts not paid by insurance within thirty (30) days of being billed by Round Rock REHAB. I UNDERSTAND AND AGREE that in the event Round Rock REHAB files any claims against balances due in Small Claims Court, or with any other source to try to collect balances due, I/we will be required to pay any handling, postage, and/or court fees. I AUTHORIZE the release of any information necessary to process any claim on my behalf. I AUTHORIZE AND REQUEST THAT ANY AND ALL BENEFITS PAYABLE BE PAID DIRECTLY AND SOLELY TO ROUND ROCK REHAB.

______Guarantor/Patient Signature Date

Round Rock Rehab, P.C. 16020 Park Valley Drive Round Rock, TX 78681 Phone: 512.388.1448 Fax: 512.388.7854 Web: www.roundrockrehab.com Email: [email protected] RRR006_v05.2012