I, the undersigned, do hereby agree and give my consent for TruMove to furnish medical care and treatment to (Patient Name) as considered necessary and proper in diagnosing or treating his/her physical condition. I understand that a PT diagnosis is not a medical diagnosis.
Please list below any other person(s) authorized by you (in addition to legal guardian, family or referring physicians) to discuss aspects related to health care provided by TruMove (e.g. lawyer, coaches, employer, etc.).
Do you now have or have you ever had any of the following:
By signing below, I hereby certify that to the best of my knowledge, all of the information I have furnished on this form is complete, true and accurate.
I understand and agree to comply with the terms of TruMove's Financial Policy Disclosure. If the patient is a minor, a signature from the parent or guardian is required.
I agree to keep my my credit card on file with TruMove for outstanding co-payments or balances due for treatment or services rendered while I was a client at TruMove. I also authorize TruMove to take payments over the phone using this information or when marked on my statement
For our patients' convenience, forms can be downloaded and filled out ahead of time.
