Patient registration 

PATIENT INFORMATION
Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Cell Phone *
Cell Phone
Spouse Phone #
Spouse Phone #
Employers Phone #
Employers Phone #
Employer's Address
Employer's Address
Referring Physician
Referring Physician
Primary Care Physician
Primary Care Physician
Person to Notify in Case of Emergency *
Person to Notify in Case of Emergency
Phone *
Phone
GUARANTOR INFORMATION
Guarantor Date of Birth
Guarantor Date of Birth
Address
Address
Phone
Phone
Work Phone
Work Phone
INSURANCE INFORMATION
Phone
Phone
Phone
Phone
COMMUNICATION
Ozark Rehab and Therapy have multiple methods to communicate with our patients. We strive to keep you up to date with all new events, specials and closures in the following methods.
If you do not want to share, feel free to navigate to our page to Like/Share with your friends and family. https://www.facebook.com/ozarktherapymo/ @ozarktherapymo
Text Messaging | Secure text messaging allows you to speak to our staff regarding your appointments, sending updated information about your account. Send Insurance Cards. Communication with your care team. Do we have permission to contact you via text messaging?
Email Messaging | Secure email allows you to: Receive important information related to Physical Therapy such as but not limited to; specials, events, important account information. Do we have your permission to contact you via email messaging?
Marketing/Advertising | We are consistently marketing and advertising our team and the services we provide. We occasionally will have photographers onsite to take updated photographs to use on our website, FaceBook, and other marketing materials. We are requesting permission to use your photographs for these purposes. Your photo is not guaranteed to be taken. When we schedule photographers we will do our best to give you notice so you can look your best. Do we have your permission to use your photographs for advertising purposes?
Protecting Your Medical Identity
Acknowledgement of Receipt-Important Company Policies