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  
Address:__________________________   City: __________________ 
State: _____  Zip: ________           
Phone number: ________________Email: _______________________
Referred by or how did you find me: _____________________________
Employment:_______________________________________________
Hobbies/recreational activity:___________________________________

EMERGENCY INFORMATION
Emergency contact name: _________________ Relation: ___________
Phone number: ___________________
Referring Doctor if applicable: _________________________________ 
Phone: _________________________________

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)

Hand dominance: Right [  ]     Left [  ]    Ambidextrous [  ]
Treatment side:     Right [  ]     Left [  ]   Bilateral [  ]  
                                                                                                                         
What is the reason for your visit and when did it start: ____________________
______________________________________________________________

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

Results_____________________________________

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

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

If you have an attorney, please provide name and phone number:
Name: __________________________Phone number___________________

Do you have allergies (latex specifically): ______________________________

Pain rating:
Rate your pain from 0-10/10: Lowest_______ Highest:_______

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 leave messages via voice mail and 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: $150.00	Follow up hour session: $130.00

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 or cancel day of your appointment, you will be charged the full amount of your appointment. If you contact me to cancel less than 24 hours, you will be charged a $75 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:________________

Student Shadowing

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

[  ] Yes	[  ] No

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

Signature: _______________________________  Date: _________________

[  ] Adult  [  ] Parent or Guardian