Patient Registration | Evergreen Physical & Occupational Therapy

Legal First Name

Legal Last Name

Date of Birth

Contact Number

Have you had surgery in the last 24 months?

Yes No

Current Assistive Devices

Cane / Walker Orthotics Wheelchair None

Primary Symptom / Area of Focus

Capture your insurance card for automatic verification. Secure and encrypted.

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What is the primary activity you wish to return to?

Functional Limitation Level (1-10)

Fully Independent Highly Restricted

I consent to receive therapy services at Evergreen. I understand that my clinical data is encrypted and handled in accordance with the .

Your medical history has been encrypted and sent to your therapist. We look forward to seeing you at your first session.

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Patient Identity