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Please print and bring completed forms with you to your first appointment. IF you have been involved in an AUTO accident for this injury please complete the additional 2 pages, Thank you.

Welcome to Foundation Physical Therapy……

The Physical Therapist

Physical therapists (PTs) are health care professionals who diagnose and treat people of all ages who have medical problems or other health-related conditions that limit their ability to move and perform activities of daily life.

PTs also help prevent conditions that limit a person's ability to move by developing fitness and wellness programs that achieve healthy and active lifestyles.

PTs examine individuals and develop plans of care using treatment techniques that promote the ability to move, reduce pain, restore function, and prevent disabilities. They provide care in hospitals, outpatient clinics, home health, nursing homes, schools, sports facilities, and more.

Care provided by a physical therapist will begin with an examination and clinical evaluation. The physical therapist will design an individualized plan of care which may include interventions such as therapeutic exercise; functional training in self-care and home management (including activities of daily living) and in community and work integration or reintegration; manual therapy, such as mobilization and manipulation; uses of devices and equipment, such as assistive, adaptive, orthotic, or prosthetic devices; electrotherapeutic modalities, physical agents, and mechanical modalities, such as ultrasound and electrical stimulation.

A PT must have a graduate degree from an accredited physical therapist education program before taking a national licensure examination from the state in which he or she practices. Physical therapists must have a minimum of a master's degree. Today most education programs offer the doctor of physical therapy degree. Please see your therapist resume which we have in the office. Foundation Physical Therapy employees 2 of the 11 Certified Manual Physical Therapist in Pinellas County.

Scheduling Process


We offer scheduling between 8:00 – 6:00 pm Monday through Thursday, and 8-1pm Friday. We schedule all the recommended appointment times after the evaluation, this way you can schedule best for your day and consistently with a particular therapist. If your schedule is not flexible, please keep in mind that it may be difficult to go through the scheduling process.


Some patients have no adverse effects after the evaluation, but others may feel sore. Keep in mind that this is normal. Treatment will begin on your next scheduled appointment. Please inform your Physical Therapist of how you felt after your examination. It appears that most patients will experience improvement around the 8th appointment. Don’t get discouraged, and keep in mind how long you have had your problem. Most patients stay 45 minutes to 1 hour. Please inform your therapist if you need accommodations for an appointment. We have had success with those patients who commit to the recovery of their dysfunction, therefore your Physical Therapist will be giving you a home exercise program within the first week of treatment. It is very important that you commit to these exercises in order to achieve your goals. Follow the instructions of your physical therapist. Your therapist may give you exercises to do at home to improve daily function and to keep continuity of care. It is very important that you comply with written and verbal instructions so that you get the most out of your time in physical therapy and achieve the maximum outcomes. Please show up on time. This is very important… Showing up late may negatively impact our treatment as well as someone else’s. Avoid Cancellations. We understand that cancellations are sometimes unavoidable, but when at all possible please call to cancel 24 hours in advance.


You will be evaluated each treatment and a formal reevaluation will be completed near the end of your scheduled treatment. At that time you and your Physical Therapist will determine if you achieved your objective goals. If skilled treatment is still indicated your physician will be sent the reevaluation to determine the need to continue or discharge rehabilitation.



Please feel free to stop by and meet Gary our office manager. He can also be reached by calling her direct line at 727-772-9286


Please feel free to ask our front office staff any questions.



We are here to please you and make your rehab experience a remarkable one. Thank you for choosing Foundation Physical Therapy.


(727) 784-6088 Clearwater office     


"Getting Results"

PATIENT’S NAME ___________________________ DATE ___________ DATE OF BIRTH __________________

HOME PHONE NUMBER: _______________________WORK NUMBER __________________________________

CELL NUMBER: __________________ SOCIAL SECURITY ________________ Email address: _________________

HOME ADDRESS: ____________________________ CITY: __________________ STATE: _______ ZIP: __________

INSURANCE: ______________________ POLICY #: __________________ GROUP #: _________________________

NAME OF POLICY HOLDER: ______________________ DATE OF BIRTH (policy holder)______________________

POLICY HOLDER SOCIAL SECURITY __________________MARITAL STATUS ( ) married ( ) single ( ) widowed ( ) divorced

EMERGENCY CONTACT: _________________________________________ PHONE ( )______________

WHO REFERRED YOU TO THE PHYSICAL THERAPIST.? _________________ PHONE ( )______________

WHO IS YOUR PRIMARY CARE PHYSICAN? ________________________ PHONE ( )______________

CARDIOLOGIST (if applicable): ______________________________________ PHONE ( )______________

OCCUPATION: _______________________________ WORK STATUS ( full, part, retired) ______________________

JOB DUTIES INCLUDE (ie lifting, carrying, desk work): ___________________________________________________

List all medications you are currently taking: __________________________________________________________




Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office with a written request.

By signing this form, you consent to our use and disclosure of protected health information about your treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996.

The patient understands that:

-Protected health information may be disclosed or used for treatment, payment or health care operations

-The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice

-The Practice reserves the right to change the Notice of Privacy Policies.

-The patient may revoke this Consent in writing at any time and all future disclosures will then cease.

-The Practice may condition treatment upon the execution of this consent.

Please list the family members or other persons, if any, whom we may inform about your general medical condition and diagnosis: ___________________________________________________________________________________


______________________________ ___________________________________________________

PRINT Patient’s/Insured’s Name Date

______________________________ ___________________________________________________

SIGNATURE of Patient/Insured (Parent Signature if Child) Date

______________________________ __________________________________________________

Practice Representative (WITNESS) Date


I hereby assign all medical/surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance and any other health plan to Foundation Physical Therapy. This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am ultimately responsible for all charges, whether or not paid by said insurance. I also understand that, should I default on my account, all costs of attorney’s fees, interest (18% annum or 1.5%per month) and cost of collections would be my responsibility. I hereby authorize said assignee to release all information necessary to secure payment and to complete disability forms on my behalf if necessary. In the case of returned checks, the fee charged by the bank will be added to your account. PATIENTS ARE RESPONSIBLE FOR NOTIFICATION OF ANY CHANGES WITH INSURANCE PLANS OR COVERAGE.

______________________________ ___________________________________________________

PRINT Patient’s/Insured’s Name Date

______________________________ ___________________________________________________

SIGNATURE of Patient/Insured (Parent Signature if Child) Date

______________________________ __________________________________________________

Practice Representative (WITNESS) Date


I hereby indicate my wish to be a participant in the rehabilitation program by Foundation Physical Therapy. I understand that the purpose of this program is to enhance my recovery from an injury or illness. I further understand that there exists the possibility that certain changes may occur during treatment. I understand that I will be informed of the procedures and methods of treatment that will be administered to me, and understand what is required of me as a patient. I verify that my participation is fully voluntary, and no coercion of any sort has been used to obtain my participation, and I may withdraw from treatment at any time. I understand that the facility administrator, Gary Parsonis 727-784-6088 maintains an open door policy and encourages calls Monday – Friday 8:00-5:00 to discuss rehabilitation issues. We understand that cancellations are sometimes unavoidable, but cancellations must be 24 hours in advance or rescheduled in the same week to avoid a cancellation fee of $25.00. No show appointments will be assessed a $25.00 no show fee. If you cancel 3 or more time, we have the right to discharge you from services. COPAYS ARE DUE AT TIME SERVICES ARE RENDERED. THERE WILL BE A $15.00 ADDITIONAL CHARGE FOR EVERY COPAY NOT RECEIVED ON THE DAY OF SERVICE.

______________________________ ___________________________________________________

PRINT Patient’s/Insured’s Name Date

______________________________ ___________________________________________________

SIGNATURE of Patient/Insured (Parent Signature if Child) Date

______________________________ __________________________________________________

Practice Representative (WITNESS) Date


I have been informed by Foundation Physical Therapy, that Medicare will not pay for Physical Therapy benefits if I am enrolled in Home Health Care, Hospice or receiving treatment at a skilled nursing facility. My signature below acknowledges that I am not receiving any of these services. I will be financially responsible for any financial liability from Foundation Physical Therapy if I were receiving these services while attending PT at Foundation Physical Therapy.

______________________________ ___________________________________________________

PRINT Patient’s/Insured’s Name Date

______________________________ ___________________________________________________

SIGNATURE of Patient/Insured (Parent Signature if Child) Date

______________________________ __________________________________________________

Practice Representative (WITNESS) Date

Foundation Physical Therapy, Inc.


Name: ________________________________________________________Date: ___________________________________

22. Thinking about all of the activities you would like to do, please mark an “X” at the point on the line that best describes your overall level of difficulty with these activities today.

23. From the above list, choose the 3 activities you would most like to be able to do without any difficulty (for example, if you would most like to be able to climb stairs, kneel, and hop without any difficulty, you would choose: 1. 12 2. 8 3. 13

1.____ 2.____ 3.____

“Reprinted from, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited.”

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