Please visit our
Coronavirus page
for the latest updates
Menu
Home
About
Staff
Services
Blog
Locations
Intake Form
FAQs
Golf Services
Contact Us
Request Appointment
New Patient Intake Form
Do you have an appointment?
*
Yes
No
Which location?
Brockport
Chili
Gates
Greece
Penfield
Pittsford
Webster
What is your preferred location?
Brockport
Chili
Gates
Greece
Penfield
Pittsford
Webster
Have you ever been a patient with Agape Physical Therapy?
*
Yes
No
Please
click here
to fill out our appointment request form for current patients.
Please select one
*
Workers Compensation Claim
Motor Vehicle Accident
Other
Next
SECTIONS
5%
95%
Patient Information
Patient Name
*
DOB
*
Address
*
City
*
State
*
Zip
*
Primary Phone
*
Cell Phone
Email Address
*
Height
*
Weight
*
Primary Care Physician
*
Referring Physician
Emergency Contact Name
*
Emergency Contact Phone
*
How did you hear about us?
*
Previous
Next
SECTIONS
20%
80%
Diagnosis/Injury Description
What is your main complaint and in what area is it located?
*
When did these symptoms begin?
*
Have you had surgery for the occurring problem?
*
Yes
No
What activities make your symptoms worse?
*
What activities make your symptoms better?
*
Have you had 2 or more falls in this past year or any fall with injury?
*
Yes
No
Please rate your pain using a 0-10 scale (0=No Pain, 10=Hospitalization)
*
Have you had any injections for your symptoms?
*
Yes
No
Have you had any other PT/OT/SLP or Homecare in last 12 months?
*
Yes
No
If Yes, for what body part(s)?
Location/Name of last therapy
Last tx date
How many total visits?
Are you under Chiropractic care?
Yes
No
If Yes, for what body part(s)?
Have you had any diagnostic testing for these symptoms?
X-Ray
MRI
CT Scan
Have you experienced any sudden weight loss?
*
Yes
No
Have you been experiencing any recent fever or chills?
*
Yes
No
Have you been experiencing any recent nausea or vomiting?
*
Yes
No
Have you experienced any abdominal pains, gassiness, or belching?
*
Yes
No
Does your pain change after or before eating?
*
Yes
No
Have you had a hospitalization within the last 6 months for this issue?
*
Yes
No
If so, when?
Have you ever had an Independent Medical Exam (IME)?
*
Yes
No
Is there any other information about your present health we should know about?
Previous
Next
SECTIONS
35%
65%
Medical History
Please check all that apply
Allergies
Arthritis
Artificial Joints/Implants
Cancer
Chest Pain
Depression/Anxiety
Diabetes
Digestive Problems
Dizziness
Eating Disorder
Fractures
Headaches
Heart Condition
High Blood Pressure
Numbness or Tingling
Osteoporosis
Pace Maker
Pregnant or planning to be
Respiratory Disease
Respiratory Problems
Seizures
Stroke
Urinary Tract Problems
Previous
Next
SECTIONS
45%
55%
Medications List
Please list all medications, including all prescriptions, over the counter medications, herbals, minerals, vitamins, and dietary supplements
Medication Name
Dosage
Frequency
Method of Administration
Medication Name
Dosage
Frequency
Method of Administration
Medication Name
Dosage
Frequency
Method of Administration
Medication Name
Dosage
Frequency
Method of Administration
Previous
Next
SECTIONS
60%
40%
Employment Information
Employer
Primary Work Duties
Are you currently working?
Yes
No
How many hours per week?
Part Time
Full Time
Please select one
Unemployed
Disabled
Student
Do you have any work restrictions due to this condition?
Light Duty
Full Duty
No Restrictions
Previous
Next
SECTIONS
70%
30%
Insurance
Insurance Company Name
Billing Address
City
State
Zip
Claim #
Contact Person/Case Manager
Case Manager Phone Number
Case Manager Fax Number
Insurance Company Name
Billing Address
City
State
Zip
Claim #
Contact Person/Case Manager
Case Manager Phone Number
Case Manager Fax Number
Please provide your personal insurance information if you would like as back up to your Motor Vehicle insurance.
Primary Insurance Company
Member ID #
Subscriber Name
Subscriber DOB
Relationship
Do you have secondary insurance?
Yes
No
Secondary Insurance Company
Member ID #
Subscriber Name
Subscriber DOB
Relationship
Previous
Next
Automatic Appointment Reminders
SECTIONS
85%
15%
Complete this form and sign below to give Agape Physical Therapy your permission to provide automatic appointment reminder service by cellular text message or automated phone call.
Agape may send me messages to confirm my upcoming appointments via
Text Message
Automated Call
I recognize that text messaging rates may apply
Phone Number
Cellular Carrier
All Tell
AT&T
Boost Mobile
Cingular
Cricket Wireless
Metrocall
MetroPCS
Nextel
Qwest
Sprint PCS
T-Mobile
US Cellular
Verizon
Virgin Mobile
Other
Please Specify Cellular Carrier
We cannot activate your text message appointment reminders without knowing your cellular carrier. If your carrier is not listed, we will be unable to activate text message alerts for you
Previous
Next
SECTIONS
90%
10%
HIPAA Acknowledgement of Receipt of Notice
I hereby acknowledge that I have been informed of the Agape Physical Therapy
HIPAA Notice of Patient Information Privacy Practices
. I give Agape Physical Therapy permission to leave voicemails regarding appointments and / or care at previously listed and below listed phone numbers. I give Agape Physical Therapy permission to discuss my information regarding Physical Therapy with the following people.
Name
Phone Number
Relationship
I give Agape Physical Therapy permission to leave a message containing information pertinent to my Physical Therapy on my answering machine and/or voicemail if they are unable to reach me directly.
I have read and agree to Agapes Financial Policy and Consent to Treat
I hereby acknowledge that I have been informed of the Agape Physical Therapy HIPAA Notice of Patient Information Privacy Practices.
*
[Commercial Insurance Patients] I understand that Agape Physical Therapy reserves the right to charge a $15 fee in the event that I do not arrive at my scheduled appointment time or I cancel my appointment with less than 24 hours notice. This fee does not apply if the appointment is rescheduled within the same Monday - Friday business week.
[Worker's Compensation / MVA Patients] I understand that I am responsible to attend appointments based on Doctors Referral and Case Manager authorization. If for any reason the patient does not abide by these guidelines, both parties will be notified.
To the best of my knowledge, the information I have given is complete and accurate. I hereby give consent to receive therapy services.
*
Parent/Guardian Name
Relationship to Patient
Signature
*
Previous