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Before Your First Visit

New Patient Paperwork

Complete your new patient paperwork before your first visit to Tristar Physical Therapy. Save time at check-in across our East Tennessee clinics.

Questions? Call (423) 317-7772

Name(Required)

Name

First Name Last Name

Preferred Name (if different than first name)

Date of Birth*(Required)

Date of Birth*

Gender(Required)

Social Security Number (SSN)*(Required)

Social Security Number (SSN)*

Address*(Required)

Address*

Street Address City State / Province ZIP / Postal Code

Mobile Phone Number*(Required)

Mobile Phone Number* (Please enter a valid phone number)

Home Phone Number

Home Phone Number (Please enter a valid phone number)

Email*(Required)

Email* (if none, please put first initial last name@noemail.com (ex: jdoe@noemail.com)

Weight*(Required)

Weight*

Height (inches only)*(Required)

Height (inches only)*

Clinic Location You Are Being Seen At?(Required)

Patient/Parents Employer Name & Phone Number

Date of Accident or Injury *

Is this related to an accident or a car wreck?*(Required)

Is this related to an accident or a car wreck?*

Yes

Name and Phone # of Adjustor (if yes above)

Emergency Contact*

Relationship

Referred By: *

Area of Complaint*(Required)

Area of Complaint*

Name of Person You Give Us Permission To Discuss Your Medical Care With:

Relationship

Is Patient A Minor?(Required)

Yes

Parent/Guardian's Name:*

Parent/Guardian's Name: (if applicable)

First Name Last Name

Parent/Guardian Address:*

Parent/Guardian Address: (if applicable)

Street Address Street Address Line 2 City State / Province ZIP / Postal Code

Relationship of Guardian*

Relationship of Guardian (if applicable)

Date of Birth of Guardian*

Date of Birth of Guardian (if applicable)

Parent/Guardian Phone Number*

Parent/Guardian Phone Number* (Please enter a valid phone number)

Social Security # of Parent/Guardian*(Required)

Social Security # of Parent/Guardian*

Insurance Information: We MUST Have A Copy Of All Insurance Cards On File

Primary Insurance*

ID# or Member ID

Secondary Insurance

ID# or Member ID

(Licensed health practitioners include a Doctor of Medicine, osteopathy, chiropractic, podiatry, dental surgery, licensed nurse practitioner, or licensed physician assistant)

Are you under the care of a licensed health practitioner?(Required)

Name of Practitioner (if yes selected above)*(Required)

Name of Practitioner (if yes selected above)*

I understand that I am a patient of Tristar Physical Therapy and their independent physical/occupational/speech therapy practitioners. My care is the exclusive responsibility of the practitioners of Tristar Physical Therapy.

Cooperation with Treatment

For therapy treatment to be effective, I must attend scheduled appointments unless there are unusual circumstances. I understand and agree to cooperate with and perform the home therapy program designed for me. If I have any trouble with my treatment program, I will discuss it with my therapist.

No Warranty

I understand that there are no guarantees regarding a cure for or improvement in my condition. My therapist will outline and discuss goals of therapy treatment for my condition and review treatment options with me before I consent to treatment.

Informed Consent for Treatment

The term "informed consent" means that the potential risks, benefits, and alternatives of therapy treatment have been explained to me. The therapist provides a wide range of services, and I understand that I will receive information at the initial visit concerning the treatment and options available for my condition.

Potential Risks

I may experience an increase in my current level of pain or discomfort, or an aggravation of my existing injury or condition. This discomfort is usually temporary. If it does not subside within a reasonable time, I agree to contact my therapist.

Potential Benefits

I may experience an improvement in my symptoms and an increase in my ability to perform daily activities. I may also experience increased strength, awareness, flexibility, and endurance in my movements, along with decreased pain and discomfort. I should gain a greater knowledge about managing my condition and the resources available to me.

Alternatives

If I do not wish to participate in the therapy program, I will discuss my medical, surgical, or pharmacological alternatives with my therapist, as well as my Physician or Primary Care Provider.

Payment

I understand that I am responsible for any charges not covered by my insurance.

Consent to Communication

By providing my contact information and scheduling an appointment with Tristar Physical Therapy, I consent to receiving SMS and/or email messages regarding my appointment status, plan of care, and follow-up visits. These messages may include reminders, updates, and other pertinent information related to my healthcare.

Additionally, Tristar Physical Therapy may send messages to follow up with me about my health status throughout and after my plan of care. These messages are designed to help provide the best possible care and may include questions about my current symptoms, health status, and any relevant inquiries.

I can opt out of receiving SMS and email messages related to my healthcare at any time by replying STOP to any message. Tristar Physical Therapy takes my privacy seriously and will only use my contact information for the purposes outlined above. I have the right to withdraw my consent at any time by contacting the office to opt-out of these communications.

By continuing to receive these messages, I acknowledge that I have read and understood this statement and agree to the terms outlined herein.

I have read the above information and I consent to Physical Therapy Evaluation and treatment.

Full Name(Required)

Date of Birth:

Patient Initials(Required)

Patient Initials

At Tristar Physical Therapy, we aim to help all patients reach a fully recovered state. Your physical therapist will provide you with a plan for care during the evaluation appointment and will inform you of the recommended number of visits to help achieve your goals. Patients who attend all physical therapy visits are 93% more likely to fully recover from an injury. Missing even one visit can lower recovery potential. We are happy to share a copy of this study with you, but we want to emphasize that attending your appointments is crucial. This policy ensures all patients receive the care they need.

Please read our policy and sign at the bottom to indicate you understand our expectations and policies.

1. Importance of Attendance

As experts, we know you will not fully recover if you do not attend your appointments. To help ensure your best chance at recovery, we will work with you to schedule all your appointments after today’s evaluation. Attending each visit is crucial for a successful recovery.

2. Arriving on Time

We aim to start your treatment sessions on schedule. For appointments after your evaluation, please arrive at least 5 minutes early, dressed for your session, and ready to begin on time. This helps our front office and specialists provide you with the care you need and deserve.

3. Late Arrivals

If you’re late, you’re missing the time specifically scheduled for your care. We cannot guarantee full treatment if you arrive late, as the following appointment time is reserved for someone else.

4. If You Are Running Late

If you’re running late, please call us immediately so we can prepare and consult with your clinician. If you are more than 15 minutes late, your session may need to be rescheduled, and a missed visit fee may apply. Chronically late patients may need to adjust their appointment times.

5. Illness Notice

We understand that illness can happen unexpectedly. We ask that you notify us as soon as possible if you’re feeling sick and cannot attend a scheduled appointment.

6. Cancellation Notice

Providing care to all patients is important to us, and last-minute changes or cancellations affect others waiting for care. If you need to cancel or change an appointment, we require 24-hour notice to assist other patients in need.

7. Rescheduling Appointments

When you call to cancel, please have your schedule ready, as we will reschedule you immediately.

8. Missed Visit Fee

We reserve the right to charge a missed visit fee of $50.00 for cancellations or changes made without 24-hour notice. This policy is applied in accordance with payer policies.

9. Avoiding the Missed Visit Fee

To avoid a missed visit fee, please call our office at least 24 hours in advance for any illness, changes, or cancellations. Our answering machine is available 24/7 for messages. Appointment reminders and progress check-ins will be sent via text. To reschedule or cancel, you must call the office as our front desk cannot access text responses.

10. Multiple Cancellations or No-Shows

Patients with multiple same-day cancellations or no-shows may be removed from the active schedule and placed on a day-to-day list to avoid further missed visit charges. We will also notify your physician.

11. Worker’s Compensation Patients

If you are a worker’s compensation patient, we must notify your claims adjuster if you cancel or do not show up for an appointment.

We look forward to working with you to achieve your physical therapy goals. To avoid any issues with our policy, we ask for timely notice of any schedule changes, helping us serve all patients with the care they need and deserve.

Tristar Physical Therapy Management