Patient Intake Form Please enable JavaScript in your browser to complete this form. – Step 1 of 8COVID-19 General Waiver of Liability This agreement releases Tampa Bay Physical Therapy LLC from all liability if I contract COVID-19 while inside the building/receiving service, etc. By signing this agreement, I agree to hold Tampa Bay Physical Therapy LLC entirely free from any liability, including financial responsibility for any medical attention required. While in the building/receiving service, etc. I agree to wear a mask over my nose and mouth at all times, stay at least six feet away from other patrons, and abide by the safety precautions laid out to me. I will ask for clarification when I need it. I understand that a mask and hand sanitizer may be provided to me if I do not have my own. I understand that Tampa Bay Physical Therapy LLC has put the aforementioned precautions into place to protect me and the other patrons. Tampa Bay Physical Therapy LLC will enforce all aforementioned precautions in order to provide maximum safety for patrons and staff. By signing this waiver, I attest that I am not currently sick, that I have not had a fever or any COVID-19 symptoms in the last 10 days, that I have not received a positive COVID- 19 test in the last 14 days, that I have not been exposed to someone with COVID-19 in the last 14 days, and that I have not traveled to a high-risk area in the last 14 days. I understand that I am at risk of contracting COVID-19 even if I take the precautions required by Tampa Bay Physical Therapy LLC and that COVID-19 can cause permanent damage, disability, and death in people of any age. I further understand that I may contract COVID-19 through my own negligence or the negligence of others in the building. By signing below, I forfeit all rights to bring a suit against Tampa Bay Physical Therapy LLC for damages, illness, or death resulting from contracting COVID-19. In return, I will receive physical therapy services. I fully understand and agree to the above terms. Clear Signature NextThank you for choosing Tampa Bay Physical Therapy LLC for physical therapy! It is our goal to provide you the most therapeutic experience possible. Please answer the questions below so that we can thoroughly address your needs. Rest assured that your information is confidential. Our therapists would like to hear your questions, comments, and complaints! We invite you to share them with your therapist in the way most comfortable for you. If you would like to see your therapist’s license, please let us know.Patient NameFirstMiddleLastPatient's Current AddressAddress Line 1Address Line 2CityState / Province / RegionPostal Code— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPatient PhoneIf registering a child, please provide the parent or guardian’s phone number.Patient Email AddressEmailConfirm EmailIf registering a child, please provide the parent or guardian’s email address.Emergency ContactEmergency PhoneNextDo You WearContactsDenturesPacemakerIn which part of your body do you experience stress?LegNeckShouldersBackHeadIs your stress level:LightModerateHeavyList injuries not requiring surgery that occurred in the past 2 years.Please list all medications you currently take (include over-the-counter medications as well as vitamins/herbs)Are you sensitive to touch in any areas?Do you have any allergies?PreviousNextPlease look over the list of health disorders and check all that apply.Bone or Joint DiseaseAllergiesTendonitisRashesBursitisAthletes FootBroken / Fractured BonesWartsArthritisConstipationNeck / Shoulder / Arm PainDiverticulitisLow Back / Hip / Leg PainIrritable Bowel SyndromeFatigueHeadaches / Head InjuriesHerpes / ShinglesSleep DisorderSpasm / CrampsTMJ / Jaw PainAnxietySprains / StrainsDepressionEndometriosisVaricose VeinsCancer / TumorsPMS / PMDDDiabetes / Type?Infectious DiseasesLymphedemaHigh / Low Blood PressureEating DisorderBruise EasilyDrug / Alcohol DisorderSinus ProblemsBlood ClotsBreathing DifficultiesHeart Conditions / DiseaseAsthmaNicotine / Caffeine AddictionChronic PainThyroid Issues (hypo / hyper)Fibromyalgia / Myofascial Pain SyndromeAdrenal IssuesIf you checked any disorders or diseases above, please use the next few lines to explain. (Example: dates, areas of disorder/disease, type, symptoms of concern. Please be specific.)Is there anything else about your health history that you think would be useful for your licensed practitioner to know to plan a safe and effective session for you?YesNoIf Yes please explain:NextAdditional Patient Information Confirm Patient Name *FirstMiddleLastDate of BirthSexMaleFemaleMarital StatusMarriedSingleWidowedDivorcedJob StatusEmployedRetiredFull Time StudentSocial SecurityEthnicityHispanic / LatinoAfrican AmericanPacific IslanderAsianWhiteRefusedReferring PhysicianPrimary PhysicianPhysician PhoneNextIs the reason for your visit the result of an accident? If yes, please complete this sectionYesNoPlease check which type of accident:Workman CompensationAutomobileOtherDate of AccidentClaim Representative / AdjusterClaim #How did the accident happen?If Workman Compensation Please Complete This Section Employer NameEmployer PhoneEmployer AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextInsurance Information Please provide your insurance card to the receptionist. Insurance CompanyInsured's Date of BirthInsurance / Card Holder's NameFirstLastRelationshipID #Group #NextConsent If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. Massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. Your Signature * Clear Signature Please sign to confirm the information provided for registration.Submit