FAX: (406) 549-5392

Patient History

Patient History

Step 1 of 5


  • Please take a moment to fill out our patient history information before your appointment. We may require additional information as well as your current insurance card(s) and photo ID, so please arrive 10-15 minutes before your scheduled appointment time.

  • Emergency Contact

    • I authorize Sapphire Physical Therapy to treat me/my child. I understand methods of treatment may include, but are not limited to: Theraputic Exercises, Manual Therapy, and other modalities as deemed appropriate by my Physical Therapist per standard of care.
    • I understand that I am responsible for all charges incurred regardless of insurance or third party liability.
    • I authorize contact by the use of my mobile/cell phone number for discussing treatment, confirming appointments and
      resolution of the balance of my account.
      I authorize Sapphire Physical Therapy to release any medical information necessary to process my claim to my insurance
      company or to any other concerned third party.
    • I understand that I will bear the cost for all associated collections and/or attorney/legal fees if my account is placed with a
      3rd party agency and/or attorney for collections or legal action.
    • I authorize my insurance company or any other concerned third party to make payment directly to Sapphire Physical
    • For patients under 18 years of age; the parent, relative or person escorting the patient is responsible for any payments due
      at the time of the service.
  • Signature required at appointment.