PATIENT REGISTRATION

Complete the form below or call to schedule 319-246-2006

Patient Registration / Demographics

Demographics

Name (First and Last)(Pronouns) *

Date of Birth

Phone *

Email *

Insurance Provider

Insurance Member ID

Seconday/Supplement Insurance

Leave N/A if you do not have one.

Seconday/Supplement Insurance ID

Leave N/A if you do not have one.

Permanent Mailing Address

Zip Code

Employer

Occupation

Emergency Contact/Relationship

Emergency Contact Phone#

What brought you in today?

How did you hear about us?

Ailment/Injury to be assessed

Side of the body?

Left

Right

Both

Referring or Primary Care Provider

Start date of symptoms

Past surgeries related to current ailment along with date of surgeries?

Is this injury the result of a Motor Vehicle Accident?

Is this a Work Comp Injury?

Acknowledgements

I acknowledge, to the best of my knowledge, that the information I am submitting is correct.

I acknowledge that I will e-mail a copy of my Insurance Card to Team Iowa's Office E-mail address listed above.

I understand my identifiable protected health information (PHI) is being sent on this platform which is not a secure platform. I understand and accept the risk of sending unsecured PHI.

For our records, please send front and back pictures of your insurance card to our office email: office@teamiowapt.com

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HOURS

Monday–Thursday 7AM–6:20PM
Friday 7AM-3:40PM
Saturday–Sunday CLOSED

Located behind North Dodge Athletic Club

CONTACT

2400 North Dodge Street, Suite B
Iowa City, IA 52245
Call: 319.246.2006
Fax: 319-483-6919
office@teamiowapt.com

HOURS

Monday–Thursday 7AM–6:20PM
Friday 7AM-3:40PM
Saturday–Sunday CLOSED

Located behind North Dodge Athletic Club

CONTACT

2400 North Dodge Street, Suite B
Iowa City, IA 52245
Call: 319.246.2006
Fax: 319-483-6919
office@teamiowapt.com