m-clubready-style.php Online Intake Form – Princeton Physical Therapy & Sports Medicine, LLC
Patient Contact Information
Please complete all information that applies to you. Fields marked with an asterisk are required.
Your Information
How did you hear about us?
Medical Information
Have you had imaging done for this specific injury? (X-rays, MRI, CT scan, ultrasound, etc.)
Consent to Treatment

I hereby authorize the professional staff at Princeton Physical Therapy & Sports Medicine, LLC to examine and treat me with physical therapy for the condition or injury for which I have been referred or for which I am seeking care.

I understand that physical therapy may include therapeutic exercise, manual therapy, neuromuscular re-education, therapeutic activities, modalities, dry needling, shockwave therapy, electrical stimulation, ultrasound, taping, and other appropriate treatment methods. I understand that results cannot be guaranteed and that I may ask questions or withdraw consent at any time.

Assignment and Instruction for Direct Payment to Health Provider

I authorize payment of medical benefits directly to Princeton Physical Therapy & Sports Medicine, LLC for services provided to me. I understand that I am financially responsible for charges not covered by my insurance plan, including deductibles, coinsurance, copays, non-covered services, and balances required by my policy.

I authorize Princeton Physical Therapy & Sports Medicine, LLC to release information reasonably necessary for treatment, payment, healthcare operations, claims processing, coordination of care, and other uses permitted by law. I understand that the clinic will protect my health information as required by applicable privacy laws.

A copy or electronic reproduction of this authorization may be treated as valid to the extent allowed by law.

Cancellation and Collection of Payment Policy

Your commitment to your physical therapy plan of care is important to your progress. If you need to cancel or reschedule, please contact Princeton Physical Therapy & Sports Medicine as soon as possible. Any cancellation or no-show fee will be handled according to the clinic's current posted policy.

Patient responsibility: Copays, deductibles, coinsurance, self-pay balances, and non-covered services are the patient's responsibility and are due according to the clinic's payment policy.

Photo / Video Release

Princeton Physical Therapy & Sports Medicine may occasionally document patient progress, clinic activities, or educational content through photographs or video. Participation is voluntary and choosing "No" will not affect your care.

Are you willing to allow Princeton PT to document your progress through photo or video?

If yes: I grant Princeton Physical Therapy & Sports Medicine permission to use approved photographs or video images for educational, informational, website, social media, and promotional purposes without payment or other consideration. I understand that I may discuss or limit this permission with clinic staff before signing.

Payment Authorization
For your security, this online intake form does not collect credit card numbers, expiration dates, or CVV codes. If Princeton PT needs a payment method on file, clinic staff can collect it through the clinic's approved payment process.
I understand that I am responsible for patient balances and will provide payment information through Princeton PT's approved payment process if requested.
Patient Responsibility
Please bring or provide your Photo ID, Insurance Card, and Prescription / Referral (if applicable) before or at your first appointment. Please do not send sensitive identity or payment-card information through unsecured email unless Princeton PT specifically instructs you to use an approved secure method.
I agree that I have read the information above and understand my patient responsibilities.
Health Questionnaire
Does your physician know you are participating in this physical therapy / exercise program?
Have you ever had heart complications, chest pain, heart attack, or stroke?
Have you ever had any type of heart surgery?
Do you have any history of blood clots or Deep Vein Thrombosis (DVT)?
Have you ever been told that you have high blood pressure?
Have you ever been told that you have an abnormal heartbeat?
Have you ever been treated for high cholesterol?
Have you ever had a stress test?
Have you used tobacco products?
Are you a dialysis patient or do you have significant kidney disease?
Do you have diabetes?
Are you pregnant or could you be pregnant?
Have you had any surgical procedures?
Have you ever been diagnosed with asthma or another respiratory condition?
Are you currently taking any medications?
Have you had a hernia or a condition that may be aggravated by lifting or exercise?
Do you have any muscle, joint, neck, back, or orthopedic disorder?
Do you have a previous injury that is still affecting you?
Do you have any history of breathing or lung problems?
Have you ever been advised by a medical professional not to exercise?
Do you have a chronic illness or other medical condition that may affect your treatment?
Have you been diagnosed with osteoporosis or osteopenia?
Have you ever had cancer?
Do you have a pacemaker, implanted defibrillator, or other implanted medical device?
HIPAA / Privacy Acknowledgment

I acknowledge that I have received or been offered Princeton Physical Therapy & Sports Medicine, LLC's Notice of Privacy Practices. I understand that my protected health information may be used or disclosed for treatment, payment, healthcare operations, and other purposes permitted by law.

Communication preferences
Questions? Call Princeton Physical Therapy & Sports Medicine at (660) 748-3600.