Patient Demographics

Emergency Contact


History of Present Conditions

Pain Drawing

Pain Rating - Please rate your pain in the scale below, circle the number that best represents your pain:

Feel Great
Nagging Pain
Hurts even more
Intense Horrible
0 Feel Great
1 - 2 Annnoying
3 - 4 Nagging Pain
5 - 6 Hurts even more
7 - 8 Intense Horrible
9 - 10 Unbearable

Patient Medical Screening Questionnaire

Authorization to Treat

I voluntarily consent to Physical Therapy consisting of evaluation and treatment procedures. I acknowledge that no guarantees have been made to me about the results of the exam and/or treatments being provided. I authorize KINECIO to provide such treatments. My healthcare provider, Insurer, or plan may require a Physician referral or prior authorization. I may be obligated for partial or full payment for therapy services rendered.

Payment Authorization

I understand that all balances designated as ‘the patient’s responsibility’ such as co-insurance, co-payments and deductibles are due and payable to KINECIO. As part of working with my insurance carrier, I understand and acknowledge that I am financially responsible for services received from KINECIO and personally guarantee payment in the event that services are not paid for by my insurance company. Further, I guarantee payment with my credit card and authorize KINECIO to charge my credit card for any unpaid account balance that remains 60 days after charge has been incurred, including co-pays, deductibles, and a service charge of $50 for each un-kept appointment.

Insurance Benefits Assignment

I authorized that the payment of my insurance benefits be made directly to KINECIO for all services delivered; if I am paid directly I will promptly pay KINECIO all monies paid to me.

HIPPA Privacy Policy

By signing below I indicate that I have been given the Notice of Privacy Practices for KINECIO Physical Therapy. I understand that outside of purposes of treatment, for payment, for certain healthcare operations or as permitted or by law I must give my written authorization to KINECIO to release any of my protected healthcare information.

Cancel/No Show Policy

We ask that if you are unable to keep your appointment, that a 24-hour notice is given. We understand emergency situations may arise and just ask that you call us as soon as possible. We will apply a service charge of $50 for each un-kept appointment. Following 2 consecutive No Shows, all future appointments will need to be prepaid by credit card, check or cash at the time of scheduling.

Record Release

I am aware that KINECIO may release any/all medical information acquired in the course of treatment to myself, my insurance company, employer, ORC or other healthcare agencies, professionals, or persons who may provide healthcare services deemed necessary for continuing my medical care.

Reminder Email/Texts

As a service to our clients, we provide reminder emails and texts regarding your appointments. By providing your phone number and email you consent to these correspondences.

*If yes, you must provide discharge papers at first appointment*