Account Visit ID:

Appt Date/Time:

1705 Jackson St. | Richmond, TX77469 | 281-341-3000

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Patient Demographic Information

Male Female

Insurance Information

Guarantor Demographic Information

(Policy Holder Information)

Same as above

Male Female

Emergency Contact/Next of kin Information

1st Contact

2nd Contact

Rehabilitation Services at OakBend
No Show/Cancellation Policy

Rehabilitation Services at OakBend Medical Center strives to provide each and every patient with personalized care and attention throughout their scheduled appointment time. In order tc maintain this high level of care, it is very important that all patients attend their scheduled appointment time. If an appointment is scheduled but not attended, it takes a valuable appointment time away from other patients who have made it a priority to work towards their physical therapy goals.

"No Show" is missing a scheduled physical therapy appointment without a call prior to that appointment to inform Rehabilitation Services at Oakbend. A "cancellation" is canceling a scheduled physical therapy appointment without giving 24 hours' notice. A "reschedule" is calling 24 hours prior to a scheduled physical therapy appointment to change that appointment to a different time or day because of a conflict.

If a patient arrives more than 15 minutes late for their scheduled appointment, they may beasked to wait until the physical therapy staff can accommodate their late arrival or may be asked toreschedule their appointment

If a patient "No Show" for more than one appointment, they will be seen when the physicaltherapy staff can accommodate their treatment without affecting other patient's quality of care.

If a patient "Cancels" any three appointments without giving 24 hours' notice to our staff,they will be seen when the physical therapy staff can accommodate their treatment withoutaffecting other patient's quality of care.

After any three "No Shows or Cancellations" Rehabilitation Services at OakBend MedicalCenter reserves the right to discharge the patient from physical therapy. Our staff will inform thereferring physician of the patient's non-compliance with attending their prescribed physicaltherapy. The patient must obtain a new prescription for physical therapy from their physicianbefore being able to return.

We understand true medical emergencies do occasionally arise when an appointment cannot be kept andadequate notice is not possible. These situations will be considered on a case by case basis.

I have read and understand Rehabilitation Services at Oakbend Medical Center's No Show,Cancellation, and Rescheduling Policies and Procedures.

Outpatient Medical History/ Subjective Information

Yes No

Medical History(Please check all that apply)

Yes NoN/A

TB Screening

Yes No
Yes No
Yes No
Yes No
Yes No

Injury/Problem Information

Yes No
Yes No
Yes No

Physical Therapy Goals and Expectations

What problems are you experiencing because of your diagnosis or injury?
What are your goals for Physical Therapy?
What do you hope to learn from Physical Threrapy?

Employment History:

Activity and Exercise History:

To the best of my knowledge and belief, the information I have given is complete and true. I hereby give my consent to receive therapy services at OakBend Medical Center. I have received a copy of the Patient/ Client Rights and Responsibilities information sheet.

Therapists Section:

Identified needs for community resources: Child/Youth Senior Adult Support Groups

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