Patient Information
First name
(MI)
Last Name:
Birthdate
Age
Social Security #
Sex
f m
Marital Status
s m w d
Address
City
State
Zip
Phone #
Alternate Phone #
Employer
Work #
Referring Physician
Primary Physician
Are you allergic to any medication?
How did you hear about us?
Email address
Emergency Contact
Name
Relationship to Patient
Phone #
Cancellation / No show policy
-We require 24 hours notice in the event of cancellation. It is your responsibility, when you call in to cancel to have an alternative time in mind that will ensure you to get in the full prescribed number of treatments for that week whenever possible. -There is a $15 charge for a cancellation without proper notice.


Patient Signature Date
Authorization for treatment and release of medical information
I hereby give my consent to perform rehabilitation therapy as prescribed by my physician in an Outpatient facility. I authorize any holder of medical and/or other information pertaining to my condition to release it to Complete Therapy USA Inc.


Patient Signature Date
Assignment of insurance benefits-treatment/charges explanation
I hereby request that my insurance carrier make payment to Complete Therapy USA Inc. for any and all services rendered to me. I, the undersigned understand that the center will bill my insurance company. I also understand that should my insurance company fail to render payment for the services received, I am fully responsible for the payments of any and all deductible and or co-insurance amounts, and that charges incurred are not subject to any payments by my insurance company. Should it become necessary for the Complete Therapy USA Inc. to engage professional collection efforts, I will be held responsible for any and additional costs of collection, including but not limited to: agency fees, attorney’s fee and interest.


Patient Signature Date


Complete Therapy USA Inc.Contact
Address 2627 NE 203 St., Suite 110,
Aventura, Florida, 33180
Phone
305-466-1388
Fax
305-466-9200