The Felice Center

Speech, Language, Occupational and Physical Therapy

New Patient Intake Form

Felice Center for Pediatric Rehabilitation
7205 Aloma Ave, Winter Park, FL 32792
Tel: (321) 972-3960     Fax: (321) 972-3960     Email: office@felicecenter.com

Patient Information

Speech Therapy Occupational Therapy Physical Therapy
Name (Last, First)
Age
DOB
Gender
SSN (optional)
Primary Phone
Secondary Phone
Mobile
Text? (Y/N)
Email
Mailing Address
City
State
ZIP Code
Primary Diagnosis
Primary Numeric Diagnosis
Secondary Numeric Diagnosis

Responsible Party

Name
Date of Birth
Gender
Relationship to Patient
Address (or "Same as above")
City
State
ZIP
Marital Status
Employer
Work Phone
Mobile Phone
Email

Referring Provider

PCP Name/Location Dr.
Phone
Fax
Specialist Dr.
Reason/Treatment for
Medications/Allergies

Primary Insurance Information

Primary Insurance Company
Policy Holder Name
Date of Birth
Policy Number
Insurance Address
City
State
ZIP
Group Number
Phone
Co-Insurance %
Co-Pay per Visit
Dedictible Met? Y/N

Scheduling Preferences
Notes

Quick-links:

Careers Free Screening Directions to the CLinic
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