New Client Intake Form

New clients should fill out the form below as completely as possible.  This will allow us to treat your conditions and symptoms in the most effective way.  We look forward to working with you soon!

Physical Therapy Questionnaire v 2.0

Client intake form for Moon Physical Therapy - Revised January 2018
  • Please enter a value between 5 and 100.
  • 0 = no pain, 10 = unbearable
  • 0 = no pain, 10 = unbearable
  • 0 = no pain, 10 = unbearable
  • Check all that apply
  • Patient Information

  • Assignment and Release

  • I hereby authorize payment directly to Moon Physical Therapy, LLC all insurance benefits otherwise payable to me or services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, for all services rendered on my behalf or my dependents.

    I authorize Moon Physical Therapy, LLC to release any information required to secure payments of benefits. I authorize the use of this signature on all insurance submissions.

    By typing my name in the field below, I am certifying it as my digital signature.

  • Office Policies

  • By my signature below, I acknowledge that I have read and understand the HIPAA privacy practices set by this clinic and Secretary of Health and Human Services. I understand that I will be given a copy of the HIPAA notice upon my request.
  • By initialing the field below, I am certifying it as my digital initials.
  • The overwhelming majority of insurance plans do not cover all treatment in full. You are responsible at the time of service for your co-­payments, all deductibles, any disputed amounts between you and your insurance company and anything that is not covered by your insurance. We cannot make exceptions, as it is illegal to do so. As we are not an insurance company, nor do we work for or represent any such company, we cannot guarantee any eligibility, extent of coverage or any payment by your insurance company. You are ultimately responsible for any outstanding balance. We want to remind you that it is your responsibility to make sure that we always have your most current insurance information on file.
  • By initialing the field below, I am certifying it as my digital initials.
  • Failing to call with less than a 24 hour notice or not showing up for an appointment hinders our ability to provide the best possible care for our patients. Therefore we have instituted a No-­Show / Late Cancellation Policy and we reserve the right to charge you at $50.00 fee. This charge WILL NOT be covered by your insurance, but WILL HAVE TO BE PAID IN FULL BY YOU prior to receiving additional treatment.

    We ask that you cancel 24 hours prior to your appointment if need be. This will allow us the opportunity to offer that appointment time to another patient.

    Two late cancellations or no-­shows will result in discontinuation of therapy. If this is the case your referring provider or case manager will be notified of the reason you were discharged.

  • By initialing the field below, I am certifying it as my digital initials.
  • I declare that I am fully aware and understand that in the event I voluntarily or involuntarily urinate, defecate, or regurgitate in Moon Physical Therapy’s pool or Hydroworx, I will pay to Moon Physical therapy $250.00 for cleaning and disinfecting. I understand that as a result I will no longer be allowed to participate in Moon Physical Therapy’s aquatic program.
  • By initialing the field below, I am certifying it as my digital initials.
  • The above information has been read and explained to me if needed. I UNDERSTAND MY RESPONSIBILITY FOR THE PAYMENT OF MY ACCOUNT.
  • By typing my name in the field below, I am certifying it as my digital signature.

Want pain relief?  

Contact Moon Physical Therapy today!

With over 15 years of experience, we can help find a treatment option perfect for your situation.  We believe in providing direct, one-on-one therapy care throughout your entire session.  At Moon Physical Therapy the quality of your treatment and patient satisfaction come first.  

Contact us today and feel better tomorrow!