New Patient Form

NEW PATIENT FORM
Patient Information (Confidential)
Patient's Name *

First Name Last Name
Birth Date *

Month Day Year
Today

Month Day Year
Date
Age
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
[email protected]
Cell Phone *

Area Code Phone Number
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
Not a problem! 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. You can still make an appointment but will need a prescription for physical therapy to continue therapy beyond 15 business days from the initial treatment session. However, if your insurance requires a referral, you will need to obtain one prior to your initial visit.

You may obtain a referral from the physician of your choice or, for your convenience, you may schedule an appointment with Dr. Cliff Maurer, DC via telemedicine to secure a valid referral. His information is on the following page.
Would you like to see Dr. Cliff Maurer for a referral? *

Yes No
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

Responsible Party
Is the patient listed the person who is responsible for this account? *

Yes No
Name of Responsible Party *

First Name Last Name
Relationship to Patient *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home / Cell Phone # *

Area Code Phone Number
Birth Date *

Month Day Year
Employer *
Work Phone #

Area Code Phone Number
Is this person currently a patient in our office? *

Yes No

Insurance Information
Have you previously been treated as a patient at Mondo Sports Therapy?

Yes No

Are you currently using the same insurance as your previous visit?

Yes No

Patient Rights & Responsibilities
Patient Payment Policy

Insurance POLICY

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

Cancellation/ No-Show Policy
If you need to cancel or reschedule an appointment, we ask that you please provide 24-hour notice to avoid any charges.

You will be asked to place a credit card on file when you schedule your initial
appointment. Credit cards are stored securely through our encrypted portal and we are
only able to view the last four digits of your card and the expiration date.

In the event you do not provide a 24-hour notice of cancellation or if you do not show
up for your scheduled appointment (including the initial appointment), your credit card will
be automatically charged a $40 cancellation fee.

For "no-shows" (meaning you do not email or call us prior to missing your appointment) there will be a $40 non-refundable fee on the first no-show. Future no-shows will incur the full cost of the appointment ($100). There are no exceptions to the no-show policy.

Patients with three or more no-shows within the same year will be required to prepay our out-of-pocket rate to hold any future appointments. The holding fee will be credited to that treatment or forfeited should you not make the 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.
Signature *

Clear
*Please use your mouse, trackpad, or finger to sign above

Consent for treatment of minor

Please read, fill, and sign below
Patient Name: First Name Last Name Date: Date

I, First Name Last Name , (Parent/legal guardian name) hereby authorize the Evaluation and Treatment of the above named minor by the physical therapists at Mondo Sports Therapy to provide routine Physical Therapy treatment for the above patient.

Routine care does not include invasive procedure or other treatments which are unusual or carry a
significant risk to the patient.

This consent form can only be revoked by written notification by the parent/guardian.
Signature of Parent/Legal Guardian

Clear
*Please use your mouse, trackpad, or finger to sign above

FORMS
Physical Therapy Treatment without Referral Disclosure

Please read carefully and acknowledge below:
I understand that physical therapy treatment without a referral will be based on the physical therapist’s examination and evaluation of my current condition which may result in identification of movement and mobility dysfunction.

I understand that the physical therapist will not diagnose an illness or disease, and that physical therapy is not a substitute for a medical diagnosis.

I understand that if a medical diagnosis has already been established by a qualified healthcare practitioner, the physical therapist will take it into consideration during the evaluation process.

I understand that the physical therapy plan of care developed by the physical therapist may not be based on radiological imaging.

I understand that if images have previously been obtained, the physical therapist may use the information as part of the evaluation process.

I understand that if the physical therapist identifies a need for radiological imaging, the physical therapist may recommend that radiological imaging be obtained.

I understand that my health insurance may not cover physical therapy services if provided without a referral from a qualified healthcare practitioner.

I, First Name* Last Name* , acknowledge that I have received the above disclosure.
Date *

Month Day Year
Today's Date
Signature of Patient or Legal Representative *

Clear
*Please use your mouse, trackpad, or finger to sign above
If signed by a Legal Guardian/Representative, type name and relationship to patient:
Full Name of Legal Guardian/ Representative
Relationship to Patient

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.
Signature *

Clear
*Please use your mouse, trackpad, or finger to sign above
Should be Empty:

NEW PATIENT FORM

Patient Information (Confidential)

Emergency Contact Information

Reason for your visit

For the following items, please use a 10-point scale with 0 being no pain or symptoms and 10 being pain or symptoms that requires you to go to the emergency room.

Health History

Responsible Party

Insurance Information

Policy Holder Information

Patient Rights & Responsibilities

Patient Payment Policy

Insurance POLICY

Cancellation/ No-Show Policy

Consent for treatment of minor

FORMS

Policy Summary

Services

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