• I consent to hands-on treatment and evaluation necessary for the care of the above patient.
    • I authorize the release of all medical records, copies of this authorization, and any information necessary for my treatment
      or claim to my health care providers and their billing agents as needed.
    • I authorize The New Jersey Centers of Physical Therapy to appeal any insurance denials on my behalf as my
      designated representative.
    • I have been made aware that The New Jersey Centers of Physical Therapy is Out of Network with most Insurance
      Companies. I understand that I have the opportunity to be serviced by an In-Network provider and instead, I have
      specifically selected the services of this Out-of-Network Health Care Provider.
    • I have discussed my financial obligations with a Client Care Specialist at The New Jersey Centers of Physical Therapy and
      understand my shared responsibility.
    • I must provide The New Jersey Centers of Physical Therapy with all Checks and Explanation of Benefits I receive from my
      insurance company for services provided. I will forward these payments within one week of receiving them. These payments
      are the legal property of The New Jersey Centers of Physical Therapy.
    • I agree to call The New Jersey Centers of Physical Therapy before my scheduled appointment if I need to cancel. If I do not
      call to cancel an appointment I agree to pay a $20.00 charge for each occurrence.

    HIPAA PRIVACY PRACTICE NOTICE
    Effective Date: April 14, 2003, Revised Date: September 23, 2013
    The New Jersey Centers of Physical Therapy is required by law to maintain the privacy of and provide individuals with a copy of our legal duties and privacy
    practices with respect to protected health information. This means The New Jersey Centers of Physical Therapy will not give out any of your personal
    information without your consent. THE NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
    AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION,
    you have the right to request the Notice of Privacy Practices prior to
    signing this consent.

    If you have any questions about this notice, please contact The Director of Clinical Services at The New Jersey Centers of Physical Therapy, 69 Newark
    Pompton Turnpike, Riverdale, NJ 07457, 973-248-8111

    I have read and fully understand all of the above.

    Patient Signature:

    Board Certified in Orthopedic and Sports Physical Therapy

    • Have you had any diagnostic testing?

    What is your AVERAGE typical symptom level? (Please indicate by filling in circle on the scale
    • None – – Worst imaginable

    Current Symptoms – Assessment

    Select the areas where you’re experiencing pain:

    LEFT :

    RIGHT :

    OTHER :

    This list provides examples of words that may help describe your symptoms. Check all that apply.

    How are your symptoms progressing recently?

    This list provides words that may help describe the behavior of your symptoms. Check all that apply.

    In the past 3 months have you experienced any of the following? (Fill Y or N)

      Fever/ Chills/ Sweats

      Unexplained weight change

       Fatigue

       Nausea/ Vomiting

       Dizziness/ Lightheadedness

       Numbness/ Tingling

       Shortness of breath

      Changes in bowel/ bladder function (difficulty, frequency, etc.)

    For WOMEN: (Fill Y or N)

    •   Are you currently pregnant?
    •   Are you taking fertility drugs? if yes,

    Board Certified in Orthopedic and Sports Physical Therapy

    Have you ever had any of the following? (Fill Y or N)

         Angina/ Chest Pain

         Kidney Disease

         High Blood Pressure

         Circulation Problems

         Depression

         Asthma

         Emphysema

         Diabetes

         Rheumatoid Arthritis

         Other Arthritic Conditions

         COVID-19

       Osteoporosis

       Anemia

       Epilepsy

       Stroke

       Tuberculosis

       Hepatitis

       Multiple Sclerosis

       Thyroid Problems

       Pacemaker

       HIV / AIDS

    •    Allergies: If yes,
    •    Cancer: If yes,
    •    Chemical dependency (e.g alcoholism): If yes,
    •    Heart Disease/ Heart Attack: If yes,
    Please list any previous surgeries, or any other condition for which you have been hospitalized

    Board Certified in Orthopedic and Sports Physical Therapy