State College Physical Therapy, Inc. dba Anaheim Hills Physical Therapy and Rehabilitation

Thank you for choosing our office. In order to serve you, we need the following information (Please print). All information will be strictly confidential.
Patient's Name: (Last, First, Middle)
Marital Status: Single □   Married □   Widow □   Divorced □
Birth date:                    Age             Sex Male □   Female □
Residence address:
Home Phone #               Work Phone #                Cell Phone #
Social Security #                              Drivers License #                 
Occupation:                                    Name of Employer:
Employer Address:                              Employer Phone #
Person Financially responsible for this account:
Address:                                       Phone #
If child, Parent's or Guardian's name:
Emergency Contact                 Relationship to patient         Phone #

Do you have medical insurance? Yes □   No □  
If yes, is it through your employer? Yes □   No □
Insurance Co. Name and address:
Subscriber name:                              Policy Number:
PPO □  HMO □  POS □  Medicare □  Medical □  Other □                          
If you do not have medical insurance.  How do you intend to pay?  Cash □   Check □
Who may we thank for referring you?
I have read and fully understand this office's Notice of Information Practices.  I hereby consent to the use and disclosure of my personal health information for purposes as noted in this office's Notice of Information Practices.  I understand that I retain the right to restrict how my personal health information is used or to revoke this consent by notifying the practice in writing at any time.

Patient's, Parent's or Guardian's Signature                                    Date