Personal Information

History

Do you smoke? *
Have you ever smoked? *
Are you pregnant? *
Do you have a pacemaker? *

Complaint

Current Duration of Pain
Current Level of Pain
Have you had this injury before? *

Do you have any of the following today?

Check all that apply:

Emergency Contact Information

Medical Information Release

I hereby give permission to Tailwind Physical Therapy to release medical information to:

As well as my physician(s), attorney, assignees, and/or beneficiaries.

Consent to Treat

I hereby consent to evaluation and treatment by my Physical Therapist at Tailwind Physical Therapy. I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examinations, test results, diagnoses, treatment, and any plans for future care of treatment. I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures, I understand that I have the right to review the notice prior to signing this consent.

Check the boxes next to each statement to confirm your consent:

Cancellation Policy

I am responsible for making all appointment changes a minimum of 24 business hours in advance or I will be charged a fee of $45.00 for the first 2 and$115.00 for each additional.

I have read and understand the terms above and agree to all terms listed: