New Patient Form

Address *

Email *
[email protected]xample.com
Cell Phone *

Area Code Phone Number
Do you have a referral? *

Yes No
Referred By

Physician / Other Health Care Provider Friend / Family Other
Who referred you?
Referring Physician / Health Care Provider *
How did you hear about us?
Do you have a prescription for physical therapy? *

Yes No
Texas Law allows patients to be evaluated and treated by a fellowship trained physical therapist for up to 15 consecutive business days without a referral.

If your insurance requires a referral you will need to obtain one prior to your initial visit. If you are going to receive treatment for longer than 15 consecutive business days, you may initiate physical therapy services but will need to obtain a referral in order to continue therapy once beyond 15 business days from the initial treatment session.

You may obtain a referral from the physician of your choice or, for your convince, you may schedule an appointment with Dr. Cliff Maurer, DC via telemedicine to secure a valid referral.
How would you like to proceed? *

I would like to schedule an evaluation I'd like to see Dr. Cliff Maurer
See Dr. Cliff Maurer via telemedicine to get a referral for PT services by clicking this link https://www.physiopartnerships.com/

Please continue filling out this form, so we can pass the information along to him.
Emergency Contact Information
Name *

First Name Last Name
Relationship to Patient *
Phone # *

Area Code Phone Number

Address *

Insurance

Please check next to each paragraph to acknowledge that you are aware of our policies:

Cancellation Policy
At Mondo Sports Therapy, every appointment scheduled has a specific time allotted on our therapists’ schedule. If our patients no-show or cancel without giving 24-hour notice, we do not have adequate time needed to fill their schedule with another appointment. Please keep this in mind should you need to change or cancel an appointment.
You can call us at 512-358-1400 or email us at [email protected]

Thank you for your loyalty, we value you as a patient and appreciate you valuing our time as well.

Policy Summary
The information provided on this sheet is true to the best of my knowledge. I authorize that my insurance benefits be paid directly to Mondo Sports Therapy. I also authorize Mondo Sports Therapy to release any information required to process my insurance claims.
Release of information

I authorize the following individuals to receive information regarding my diagnosis, treatment, and billing:
Name
Relationship
Name
Relationship
Name
Relationship
How would you prefer we contact you to schedule your appointment? *

Phone Email No preference
Patient / Guardian Signature *

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NEW PATIENT FORM