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               730 NW Gilman Blvd, Suite C-108, Issaquah, WA 98027 * Phone 425-391-6794 Fax 425-391-1525
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(Please Print)
Patient's Last Name ___________________________________ First Name____________________________ Middle ____________

Address ________________________________________________________________Apt______________________________

City _____________________________________________State__________________________________Zip__________________

Home Phone (______)__________________ Work Phone (______) __________________ Cell Phone (_____) _________________

Social Security # ________-______-________ Drivers Lic #/ ID# _______________________ Date of Birth _____/_____/________

Employer Name________________________________________ Job Title/ Occupation ____________________________________

Emergency Contact _______________________________________ Phone___________________ Relationship:_________________

Relationship:      Self   Spouse   Parent   Other      Insurance Company Name _______________________________________
Address_____________________________________ City __________________________ State____________ Zip _____________
Insurance Company's Phone (_____)_______________________
Adjuster’s Name _________________________________________Adjuster’s Phone Extension ______________________________
Policy Holder’s Last Name_______________________________ First Name______________________ Middle ________________
Policy Holder’s Address________________________________________ City __________________ State______ Zip ___________
Policy Holder’s Date of Birth ______/_______/_______ Policy Holder’s Employer ________________________________________
Policy Holder’s Social Security Number ________-_______-________ Claim Number _____________________________________
Accident Date ______/_______/_______ Attorney Name __________________________________ Phone _____________________

Relationship:      Self   Spouse   Parent   Other      Insurance Company Name _______________________________________
Subscriber's Last Name _________________________________ First Name ________________________ Middle ______________
Subscriber’s Address___________________________________________ City __________________ State______ Zip ___________
Subscriber's Date of Birth_______/________/________ Subscriber's Employer ____________________________________________
Subscriber's Social Security Number _________-_______-_________ Group Number ______________________________________

Additional Information
Have you been to any other Physical Therapy clinic this year?       □ Yes □ No   # of Visits ________
Have you been to any Chiropractic clinics this year?                □ Yes □ No   # of Visits ________
Have you been to any Other Therapy (MT, OT, ST) clinic this year?   □ Yes □ No   # of Visits ________
Consent for care 01/11                                                                                          1
                                                     CONSENT FOR CARE
Please read carefully and sign prior to treatment. If a copy of this release is desired, one will be provided for you.

It is our policy to bill your insurance carrier as a courtesy to you, although you are responsible for the entire bill when
services are rendered. If your insurance carrier does not remit payment within 90 days, the balance will be due in full
from you. If any payment is subsequently made by your insurance carrier in excess of the balance of your account, we
will promptly refund the credit. If any payment is made directly to you for services billed by us, you recognize an
obligation to promptly remit the same to BALANCE PHYSICAL THERAPY INC, PS. All past due patient balances over 30
days will be subject to a $25.00 per month administrative late fee and interest charges of 12% per annum (1% per month).

As of 01/01/2009 we require that patients with unmet deductibles of $300 or more will need to make a minimum payment
of $100 per visit due at time of service. This payment per visit will be collected until your deductible is met. This
minimum payment of $100.00 will be applied to your actual amounts owing for each date of service. If at any time it is
determined that BALANCE PHYSICAL THERAPY INC. PS has collected more than you owe, a prompt refund will be made.

The above does not apply for those patients that are considered Worker's Compensation. However, be advised as a
Compensation patient that you may be held responsible for your charges in the event that your claim is controverted.

I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, after such
default and upon referral to a collection agency or attorney by BALANCE PHYSICAL THERAPY INC, PS, I will be
responsible for all costs of collecting monies owed, including court costs, collection agency fees and attorney fees.

I hereby consent to and authorize all physical therapy treatments and procedures which may be considered advisable or
necessary in the judgment of the patient's physical therapist. BALANCE PHYSICAL THERAPY INC, PS may disclose
portions of the patient’s records to any person, insurance company or corporation which is or may be liable for all or any
portion of the charges for treatment. I assign my benefits under my medical insurance plan to BALANCE PHYSICAL

Should any provision or portion of this Agreement be held unlawful or unenforceable, the balance of this Agreement shall
be nonetheless in all respects remain binding and effective and shall be construed to be in full force and effect to the
extent lawfully permissible.

Patient, Parent, or Guardian Signature ___________________________________________ Date                          /        / 2011
Relationship to patient ___________________________________ Witness ______________________________________

                                                  CANCELLATION POLICY
In order to best serve our patients, it is necessary to give 24 hour notice of cancellation for any scheduled physical therapy
appointment with BALANCE PHYSICAL THERAPY INC. A $40 nonrefundable charge will be billed to you for any
appointments that are missed and not canceled at least 24 hours prior to the appointment. This applies to late
cancellations and no shows. This charge will not be billed to your insurance and is your responsibility due at your next
scheduled appointment. We understand that emergencies and illness do occur that are out of our control, and BALANCE
PHYSICAL THERAPY reserves the right to waive cancellation charges.

I agree to the above cancellation policy:_________________________________________ Date                      /           / 2011

Consent for care 01/11                                                                                                             2

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