Form

Responsible Party Information

(Required if patient is a minor)

Responsible Party Name

Date of Birth

Age

Sex Male Female

Marital Status Single Married Other

Address

Apt #, Suite #

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email Address

Employer Name

Employment Full Time Part Time Retired Student

Consent to Treatment of Minor Child

I , am the parent/legal guardian of who is currently a minor, whose date of birth is . I hereby authorize Hand & Orthopedic Physical Therapy Specialists to provide physical/occupational services as may be considered necessary or appropriate under the circumstances. I further understand that once my child reaches the age of majority, my consent for treatment is no longer required.

Patient Information

Referral and Injury Information

(Please note that Medicare patients must provide a presciption from a doctor to receive therapy)

Additional Care

Responsible Party Information

Consent to Treatment of Minor Child

Surgical / Health History