Meredith Hoerske, OTR/L CO Lic #1866
Occupational Therapist/Hand to Shoulder Specialist
3775 Iris Ave, Ste 2 A & B Boulder, CO 80301
P: 720-760-3222 ~ F: 720-664-6504
frontrange.rehab@gmail.com 

Date______________ 
Client Information
PERSONAL INFORMATION
Patient Name: ______________________________________
Birthdate:  ______________    ☐  Male   ☐ Female   ☐ Nonbinary
Address:______________________________ City: ____________ 
State: _____  Zip: __________           
Phone number: _________________ Email: ______________________
Referred by / how did you hear of me: ___________________________

EMERGENCY INFORMATION
Emergency contact name: _________________ Relation: ____________
Phone number: ___________________

HEALTH HISTORY
Please list any current medications here:
__________________________________________________________
__________________________________________________________

Do you have or ever had any of the following conditions?(check all that apply)
[  ] Cardiac Issues 		[  ] Headaches           [  ] Fractures
[  ] Pacemaker 		[  ] Auto-immune 	[  ] Arthritis
[  ] Hepatitis			[  ] HIV +/AIDS	[  ] Stroke
[  ] Diabetes			[  ] Cancer		[  ] Anxiety/Depression/PTSD
[  ] High/Low Blood Pressure			[  ] Spinal Issues
[  ] Thyroid (hypo/hyper)
                                                                                                                         
What is the reason for your visit and when did it start: ____________________
______________________________________________________________

Did you have surgery related to this injury: No [  ] Yes [  ] 
Date of surgery: ______________________

Have you had recent imaging related to this injury: X-ray [  ] MRI [  ] 

Results_____________________________________	

If this was a result of an accident, is there an attorney involved: No [  ]  Yes [  ]  NA [  ]

Do you have allergies (latex specifically): ___________________________

Pain rating:
Rate your pain from 0-10/10:

At rest_______ With use_______At end of day______

CONSENT TO TREAT AND HIPAA AUTHORIZATION

I, (your name)_________________________, give my therapist, Meredith Hoerske, OTR/L 'consent to treat' in regards to my treatment goals.
 
I, (your name)_________________________, give my consent for my therapist, Meredith Hoerske, OTR/L, to communicate about my personal medical information or discuss my injury and status with the doctor and/or (referring) provider (chiropractor, PT, acupuncturist, etc.). HIPAA privacy laws are strictly adhered to; no information is shared with third parties without your explicit consent.
Initial:_______________

COMMUNICATION

I authorize Meredith Hoerske, OTR/L with Front Range Upper Extremity, LLC to communicate with me via Google platforms, email, chats via website/Square, as well as text messaging. 
								  Initial:_______________

RELEASE OF INFORMATION (if applicable)

I authorize (physician's name)______________________________ to release any of my medical records, x-rays or reports to Meredith Hoerske, OTR/L with Front Range Upper Extremity Rehab for the purpose of obtaining medical information pertaining to my treatment. I also authorize Front Range Upper Extremity Rehab to release my medical records to the above physican or physicians.   

Initial: _______________

FINANCIAL AGREEMENT

I (your name) ______________________________ will pay the agreed amount at the time of service to Meredith Hoerske, OTR/L with Front Range Upper extremity Rehab. 
Initial evaluation: $130.00	Follow up hour session: $110.00

Initlal:________________

CANCELLATION POLICY

I realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable. However, advance notice allows me to fulfill my other client’s scheduling needs and keeps my business operating at is most efficient level.
A 24-hour notice is required to change or cancel an appointment. If you no-show for your appointment, you will be charged $75. If you contact me to cancel less than 24 hours, on a frequent basis, you will be charged a $40 cancellation fee that will be due at the time of your next scheduled appointment. Weather and emergencies are exceptions. PLEASE CALL, EMAIL OR TEXT TO CANCEL YOUR APPOINTMENT IF YOU HAVE COLD/FLU SYMPTOMS OR HAVE BEEN OR HAVE POSSIBLY BEEN EXPOSED TO COVID.

Initlal:________________

HAVE YOU TRAVELED OUT OF STATE AND/OR BEEN ON AN AIRPLANE IN THE PAST 3 WEEKS?

YES________	NO________ (if yes, please have your mask with you.)

Student Shadowing

Are you comfortable with potentially having a student shadowing our therapy sessions?

[  ] Yes	[  ] No

I have read, understand and agree to abide by the above policies. 

Signature: _______________________________  Date: _________________

[  ] Adult  [  ] Parent or Guardian