Core Physical Therapy 

                                                                             1971 Western Avenue  Albany, NY, 12203                               1 Rosell Drive  Ballston Lake, NY 12019                  

Phone: (518) 869-6220  

Fax: (518) 869-6465

Patient Information 

Patient's Name: _______________________________________________ DOB: ____/____/_____

Patient's Address (No., Street): _______________________________________________________

City/ State/ Zip Code: ______________________________________________________________

Place of Work: _________________________________ Home #: ________________ [  ] voice reminder  

Work Address: ______________________________Cell #: ________________ [  ] text [  ] voice reminder  

                     __________________________________ Work #: __________________

Email Address: _____________________________________________ [  ] email reminder

Primary Care Physician (PCP): ______________________________ PCP Phone #: ___________________

Are you currently seeing a chiropractor?    Y / N      Date of last visit: ____________________     

Have you been to physical therapy in the past year?  Y / N Date of last visit: __________________

Current Reason for physical therapy?: ______________________________________________________

 

Insurance Information 

Insurance Plan Name: ______________________________________ I.D. #: _______________________ 

Policy Group #:  _______________________________________________________________________

Secondary Insurance:  ______________________________________I.D. #:_______________________

I authorize the release of the above information to process this claim. I am also responsible for charges if my insurance company fails to pay for services rendered.

Signature: _____________________________________________ Date: _________________________

 

Privacy Practice Acknowledgement 

I have received the notice of Privacy Practices and I have been provided an opportunity to review it.

 

Patient's Name: _______________________________________________ DOB: ____/____/_____

Signature: _______________________________________________ Date: _______________________