New-Patient Intake

Welcome to Tristar · (423) 317-7772 · tristarpt.com

Welcome! Please complete this form so we can give you a positive, unforgettable experience from your very first visit. Type below or print and fill it in by hand, and bring it to your appointment.

Patient Information

Full name

Date of birth

Sex

Date

Address

City / State / ZIP

Mobile phone

Preferred location

Emergency contact

Emergency phone

Insurance & Referral

Insurance carrier

Member ID

Group #

Referring physician

Primary care provider

How did you hear about us?

Reason for Visit

Primary concern / area of pain

When did it start?

Current pain level:

012345678910

Briefly describe your symptoms & goals

Health History

Current medications

Allergies

I certify the above information is accurate. I consent to evaluation and treatment, and I acknowledge receipt of Tristar Physical Therapy's Notice of Privacy Practices (HIPAA).

Patient / guardian signature

Date

Tristar Physical Therapy — 8 locations across East Tennessee
(423) 317-7772 · Fax (423) 317-7773 · tristarpt.com

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New-Patient Intake

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