Patient Info / Forms

What you should expect from your first physical therapy visit:

We offer many convenient appointment times, however, prime times can become busy, so it is best to book ahead as much as possible.

If you have any questions at any time, please don’t hesitate to call. We want to ensure your satisfaction and full recovery.

Want to save time?

Be sure to fill out your new patient forms prior to your appointment

If you would like to save time on your first visit, please print the following patient documents below, fill them out, and bring them with you to your first appointment.

1

Medical History

Download & Print

2

Cancel Policy

Download & Print

3

Notice of Privacy Practices

Download & Print

Patient Registration Form

you can save time and fill out the form online and submit it.

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X/Twitter

This field is for validation purposes and should be left unchanged.

PATIENT REGISTRATION

Name(Required)

First

BIRTH DATE(Required)

MM slash DD slash YYYY

Address(Required)

Gender

Male

Female

City/Zip

Marital Status(Required)

Home

Other

Work

Social Security Number

Employer

Referring Dr

Physician/PCP

Body Part(Required)

Condition(Required)

Emergency Contact

Main Phone(Required)

Email Address(Required)

How Did You Hear About Us?

HAVE YOU HAD PHYSICAL THERAPY SERVICES AT HOME WITHIN THE LAST 30 DAYS?

Yes

No

If so, please bring this to the receptionist’s attention immediately. Medicare may not cover your outpatient physical therapy services if this applies to you.

INSURANCE INFORMATION

Payment Method *(Required)

I will be paying Privately

I will be using Insurance

Policy Holder(Required)

Policy Holder Birth Date(Required)

MM slash DD slash YYYY

Insurance name(Required)

Policy number(Required)

Policy Holder Address(Required)

Relationship to Patient(Required)

Policy Holder City/Zip(Required)

S.S.#(Required)

Employer(Required)

***FOR MEDICARE ONLY: ***
As of January 1, 2025, the U.S. government has implemented a $2440 cap for all physical therapy services received during the course of the year. Our estimation is that the cap will cover an average of 20 physical therapy visits for the year, barring the use of other rehabilitation services. This cap encompasses physical therapy, speech therapy, and some chiropractic services together, limiting your Medicare coverage even further; anyone exceeding this limit may be responsible for the services rendered. There are exceptions to the cap on a case by case basis and the details should be discussed with your physical therapist.

PLEASE INITIAL HERE

***FOR MINORS ONLY: ***
I hereby give permission for my child to be treated at Darien Physical Therapy under a prescription from Dr.

Doctor Name(Required)

for treatment of

treatment

I understand and accept responsibility for all fees and agree to pay at each therapy session for services rendered.

FINANCIAL RESPONSIBILITY AND SIGNATURE

I hereby authorize the release of any information required during the course of my treatment necessary to process insurance claims. I also authorize my insurance to make payment directly to Darien Physical Therapy Center, P.C., otherwise payable to me for services rendered, realizing that charges are submitted to my insurance as a courtesy to me and that I am solely responsible to pay for non-covered services and any applicable co pays and/or deductibles. By signing below, I acknowledge that I understand that I will be charged, and not my insurance company, for a missed appointment or cancellation within 24 hours of my scheduled appointment time.

TAKE CONTROL OF YOUR HEALTH TODAY!

At Darien Physical Therapy, we can develop an exercise program that is tailored to your individual needs and health goals. Physical therapy can also help you identify and address any underlying issues that may be causing pain or discomfort. Whether you are looking to prevent injuries, reduce pain and stiffness, or improve your overall physical fitness, we can help you reach your goals and take control of your health.