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New Patient Agreement Form

New Patient Agreement

Permission for Evaluation and Treatment: I hereby give permission to the professional staff of Polygon HQ to perform any test(s) and give any treatment(s), deemed appropriate by the professional(s) responsible for my care. I understand that I may contact Parth Shah (partner) at any time if questions or concerns arise.

Team Approach: Polygon HQ integrates the professions of Physical Therapy, Nutritionist, and Personal Training in physical rehabilitation, injury prevention, and general wellness. I understand that I may be treated by more than one professional over the course of care at the discretion of the professional performing the initial evaluation. I understand that there is a high level of communication between the providers of my care, verbal and written, in providing the optimum attention. If I feel most comfortable with one provider, I have the freedom to request that individual for my care. My initial evaluation will be provided by an insured provider who provides care to a broad range of patients and diagnoses.

Use and Disclosure of Health Information: I have been shown a copy of Polygon HQ Uses and Disclosures of Health Information Statement. I may request a copy if needed. I understand and accept the Polygon HQ HIPAA compliant policy.

Potential Benefits, Risks, and Alternatives: I may experience an improvement in my symptoms, such as decreased pain and discomfort, and an increase in my ability to perform daily activities as well as increased strength, awareness, flexibility and endurance in my movements. I understand that I may temporarily experience an increase in my current level of pain or discomfort and that if it is not temporary or subsides, I agree to contact the Polygon HQ professional providing my treatment. I understand that I should gain a greater knowledge of managing my condition and the resources available to me.

Informed Consent: The potential benefits, risks, and alternative treatment options for my condition and the wide range of services Polygon HQ offers have been explained to me.

Release of Information: I hereby authorize Polygon HQ to release any information necessary in coordination of my care to my insurance company(s), my attending physician(s) and/or case manager(s).

Personal Property Statement: I hereby release Polygon HQ of any responsibility for the loss or theft of any personal items left in any section of Polygon HQ. It is understood that any item may be placed in the hands of a person at reception desk of Polygon HQ for safe keeping.

PAYMENT AGREEMENT: I permit Polygon HQ to bill my insurance carrier directly and request any payments for service to be made directly to Polygon HQ. I certify the insurance identification information given by me is correct. I understand that I am responsible for and agree to pay all applicable copays, deductible amounts, and charges not covered by my insurance at the time of treatment. If I do not use my insurance I agree to pay all charges that may be applicable for any and all services rendered. If my obligations cannot be paid at the time of treatment, I agree to a payment schedule. I understand that I am responsible for payment at the time of treatment. 

 

First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
How did you hear about us?
Insurance
Internet
Referral
Other

If referral, who referred you?

If other, please describe how you found out about us.
Insurance Specific Patients
Are you using insurance to pay for your visit(s)?*
Yes
No
N/A

If so, please provide the name of your referring and/or primary care physician.

Which insurance company are you with?

Insurance Member ID
Media Release Form
I grant permission to Polygon HQ to use my image (photographs and/or videos) for use in media publications including but not limited to: Videos, Newsletters, Brochures, General Publications, Website, Social Media Accounts, etc.*
Yes
No
I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used with them now or in the future whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.*
Yes
No
Credit Card on File Agreement

Polygon HQ Physical Therapy has implemented a credit card on file policy. Much like many other businesses such as a hotel or car rental agency, attorneys, etc. we now have a similar policy where we ask for a credit card which may be used later to pay any balance that may be due on your bill. 

Co-pays are still due at the time of service. 

At check in, your credit card information will be obtained and kept securely until your insurance(s) have paid their portion and notifies us of the balance due, if any. At that time, you will be sent a statement which you will have 30 days to pay or set up a payment plan with us. After 30 days, if the bill remains unpaid or unaddressed, we will bill your credit card. 

Your ability to dispute a charge or question your insurance company's determination of payment will remain unchanged. 

If you have any questions about our policy, please do not hesitate to ask.

- *
By acknowledging here, I authorize Polygon HQ Physical Therapy to keep my signature and my credit card information securely on-file in my account.
- *
By acknowledging here, I authorize Polygon HQ Physical Therapy to keep my signature and my credit card information securely on-file in my account.
- *
If the credit card that I give today changes, expires, or is denied for any reason, I agree to immediately give Polygon HQ Physical Therapy a new, valid credit card which I will allow them to charge over the telephone. Even though Polygon HQ Physical Therapy is not processing the new card in person, I agree that the new card may be used with the same authorization as the original card I presented.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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