Microsoft word - patient application form pdf

PATIENT APPLICATION FORM
461 West Huron St. - Suite 406, Pontiac, MI 48341
1-888-875-6662 ~ Fax: 248-857-7102
www.europeds.org
*PLEASE FILL OUT THIS APPLICATION COMPLETELY. ANY UNANSWERED QUESTIONS WILL
DELAY THE APPLICATION PROCESS. THANK YOU.
CHILD'S NAME: ___________________________ DATE OF APPLICATION: ______
DATE OF BIRTH: ____________________ AGE: _____________ M: ___ F:___
PARENT/GUARDIAN NAMES: ____________________________________________
ADDRESS: ___________________________________________________________
___________________________________________________________________
PHONE #: HOME ____________________ CELL ____________________________
WORK ____________________________ E-MAIL: __________________________
1. WHAT ARE THE CHILD’S DIAGNOSES: ___________________________________
_________________________________________________________________
2. WHAT IS THE CHILD’S HEIGHT: _______________ WEIGHT: ________________

3. CURRENT MEDICATIONS (Also include reason for taking):
4. PLEASE PROVIDE PHONE NUMBERS TO SPECIALISTS WHO TREAT YOUR CHILD:
______________________
461 West Huron Street, Suite 406, Pontiac, MI 48341 (248) 857-6776 or Toll-free (inside the U.S.) 1-888-875-6662 Never Underestimating a Child since 1999
CHILD'S NAME: _________________ DOB: _______
5. PAST MEDICAL HISTORY:
____________________________
PLEASE INDICATE IF YOUR CHILD HAS A HISTORY OF THE FOLLOWING (DESCRIBE):
SEIZURES (How often/date of last occurrence?): _________________
SCOLIOSIS (What degree of scoliosis?):
HIP SUBLUXATION (What %?):
FRACTURES:
VISION/HEARING PROBLEMS: _______________________________
VENTRICULOPERITONEAL SHUNT (Hydrocephalus):
GASTROINTESTINAL TUBE (G-Tube):
TRACHEOSTOMY TUBE (Trach):
BOTOX/PHENOL INJECTIONS: ________________________________
HEART, LUNG, KIDNEY, DIABETES, etc:
461 West Huron Street, Suite 406, Pontiac, MI 48341 (248) 857-6776 or Toll-free (inside the U.S.) 1-888-875-6662 Never Underestimating a Child since 1999
CHILD'S NAME: _________________ DOB: _______
6. SURGICAL HISTORY (muscle or tendon lengthening/releases, selective dorsal rhizotomy,
baclofen pump, spinal fusion/rods, osteotomy, reconstructive joint surgeries, etc):
7. HAS YOUR CHILD RECEIVED OTHER PHYSICAL THERAPY SERVICES THIS POLICY YEAR?
(If yes, how often and where? This helps us determine tolerance to therapy and also
insurance coverage)
________________
8. PAST & CURRENT MEDICAL EQUIPMENT (braces, walker, crutches, wheelchair, etc):
____________________________
9. CHILD’S ABILITIES (rolling, sitting, crawling, walking, etc):
10. HOW DO YOU COMMUNICATE WITH YOUR CHILD/HOW DOES HE OR SHE
COMMUNICATE WITH YOU?
11. IS YOUR CHILD ABLE TO FOLLOW SIMPLE COMMANDS?
___________
12. HAVE YOU EVER BEEN DENIED THERAPY AT EURO-PĒDS? (If yes, please explain)
_________________________________
13. HAS YOUR CHILD RECEIVED THEIR IMMUNIZATIONS? (If no, please explain):
______________________________________________________________________
461 West Huron Street, Suite 406, Pontiac, MI 48341 (248) 857-6776 or Toll-free (inside the U.S.) 1-888-875-6662 Never Underestimating a Child since 1999
CHILD'S NAME: _________________ DOB: _______
14. HOW DID YOU HEAR ABOUT EURO-PEDS? _______________________________
_________________________________________________________________
15. REFERRING PHYSICIAN:_____________________________________________
ADDRESS:________________________________________________________
PHONE:_________________________ FAX:____________________________
LICENSE #:________________ EXP DATE:_______ NPI #:_________________
*If you would like to participate in SUIT THERAPY, please know that there will be 1-2
additional steps to take. Once your child is approved for Intensive PT and his/her session is
scheduled, your child will need to have Hip X-rays taken within 6 months of his/her
admission. Those X-ray films will then need to be brought to Euro-Pēds your first day
(unless notified otherwise) to determine if your child is a candidate for Suit Therapy. If
there is a possibility of scoliosis or other spinal abnormalities, spinal X-rays within 6 months
of admission will also be needed.
INSURANCE INFORMATION:
1. PRIMARY INSURANCE COMPANY:______________________________________
SUBSCRIBER:___________________ SUBSCRIBER’S DATE OF BIRTH:________
EMPLOYER:____________________ PROVIDER PHONE #:__________________
CONTRACT #:__________________________ GROUP #: ___________________
2. SECONDARY INSURANCE COMPANY:____________________________________
SUBSCRIBER:___________________ SUBSCRIBER’S DATE OF BIRTH:________
EMPLOYER:____________________ PROVIDER PHONE #:__________________
CONTRACT #:__________________________ GROUP #: ___________________ 461 West Huron Street, Suite 406, Pontiac, MI 48341 (248) 857-6776 or Toll-free (inside the U.S.) 1-888-875-6662 Never Underestimating a Child since 1999

Source: http://www.europeds.org/upload/docs/EuroPeds/pdfs/Patient_Application_Form_PDF.pdf