Intake Form

    I. Personal Information

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    II. Current Symptoms

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    III. Medical History

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    IV. Authorization

    I authorize my insurer to pay any benefits for physical therapy services to SSPTS. I understand that anything not covered by my insurance is fully my responsibility. I hereby authorize SSPTS through its appropriate personnel to perform or have performed on me, or the patient named below, appropriate assessment and treatment procedures relating to my diagnosis. I further authorize SSPTS to release to appropriate agencies any information acquired in the course of my examination/treatment and permit a photographic or other facsimile or this authorization to be used in place of the original assignment. I have reviewed and understand the notice of privacy practices. A copy of this authorization will be provided upon request.

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