New Patient Form

Address *

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
Texas state law currently requires a referral before any treatment can be provided. We CAN do an evaluation without a referral, but we would will not be able to perform follow-up treatment without a referral.

Alternatively, we could refer you to see Cliff Maurer 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 Cliff Maurer
(INSERT NEXT STEPS/CONTACT INFO HERE)

Please continue filling out this form as this information, 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 *

Clear
Today's Date *

/ Month / Day Year
Should be Empty:

NEW PATIENT FORM