Canal Fulton Clinic Online Intake Forms

Below are the online intake forms for the CANAL FULTON CLINIC.

Please be sure to fill out all 3 forms.

New Patient Information Form

Date

YYYY

Child's Name

First Name

Last Name

Date of Birth

YYYY

Age

Sex

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parents/Guardian Name

First Name

Last Name

Parent/Guardian Address

Only fill out if parent/guardian address is different than child's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Number

(###)

###

####

Home Phone

(###)

###

####

Email Address

Referring Physician/Pediatrician

Physician Phone Number

(###)

###

####

Medical Diagnosis

Insurance company (primary)

Policy Holder's Name

First Name

Last Name

Policy Holder Date of Birth

YYYY

Insured ID #

Group #

If unknown add 1111

Policy #

If unknown add 1111

Coverage-How many visits will insurance cover for your child to receive per year?

Deductible Amount

Co-pay

Does your plan require pre-authorization for OT/PT/SP visits?

Is child covered under another insurance policy?

If so, please provide secondary insurance information here

PLEASE BRING YOUR INSURANCE CARD TO THE FIRST VISIT

New Patient Medical Information

Child's Name

First Name

Last Name

Date of Birth

YYYY

Was your child born full term or premature?

If your child was born premature, how many weeks?

Was your child placed in NICU following birth? If so, for what reason(s) and how long?

Are your child's immunizations up to date?

List allergies:

Current medications:

Does your child use special equipment (ex. Braces, splints, adaptive utensils)?

Has your child received occupational/physical/speech therapy before? If so, which one and for how long?

Date of last evaluation (if this is not applicable to your child, please put N/A)

What are your main concerns with you child?

Is there anything else our therapists should know regarding your child that may assist us in working with them?

Emergency Contact/Allergies Form

Parent's Name

First Name

Last Name

Child's Name

First Name

Last Name

Emergency Phone Number

(###)

###

####

Allergies

Other Information

There are other forms that require signatures that will be filled out at the first visit. Please take a look at them here:

Privacy Notice

Release of Information and Photo Release Form

Therapy Policies and Consent