New Patient Form

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Patient Information

Today's Date

First name

Last name

Middle initial

Date of Birth

Gender

MaleFemale

Home phone

Cell phone

Emergency contact

In case of emergency, who should we notify?

Patient referred by

How did you hear about Wave Fit?

Preferred method of communication

EmailPhone CallText Message

Primary Insurance Information

Insured’s Name

Group / ID#

Insurance Company

Secondary Insurance Information

Insured’s Name

Group / ID#

Insurance Company

General Medical Information

Referring Physician's Name

Previous Complaints / Surgeries

Current Complaints / Reason for Therapy

Current Medications

‍CANCELLATION POLICY
Appointments cancelled less than 24 hours before scheduled time will incur a $50 fee. This fee also applies to no-show appointments. Your insurance provider will not cover this fee. In case of an emergency, please contact the WaveFit office to determine if the fee can be waived. Patients who arrive more than 15 minutes late may need to reschedule their appointment.‍

‍CONSENT FOR TREATMENT
I, the undersigned, do agree and give my consent for WAVEFIT to render care and treatment as considered necessary and proper in evaluating and treating my physical condition.

CONSENT FOR TREATMENT OF A MINOR
As a parent and/or legal guardian, I authorize WAVEFIT to treat the minor patient while I am not present.

The above information has been read and/or explained to me.

Patient/Parent/Guardian name

Please type your name below in lieu of signature

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New Patient Form

Patient Information

Primary Insurance Information

Secondary Insurance Information

General Medical Information

WAVEFIT PT

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