Patient Forms

We want to make your experience with us as comfortable as possible. In order to begin your treatment and expedite your therapist's initial evaluation, please take a few minutes to download, read over, and fill out the forms below and bring them with you to your appointment:

• The Patient Registration Form, completely filled out and signed by the person financially responsible for your care.
• Informed Consent for Physical Therapy. Please print your name, sign it and put the date on the form.
• The Payment Information and Contract, initialed on the first page, and signed on the second page by the person financially responsible for your care.
• The Health History Questionnaire. Please fill out the front page, letting us know why you are coming and what other medical issues we need to be aware of. On the remaining pages, please check the box next to any activities you are having problems with in any way. Use the right hand column to explain any details you wish.
• Notice of Patient Information Practices. Please read and print a copy of the consent form on the fourth page of this Notice that we are required to give you for the Health Care Portability and Accountability Act (HIPAA).
• For our Medicare patients only:
1. The Notice of Exclusion From Medicare Benefits, required by CMS, must be signed by the person being treated.

Along with the forms listed above, please also bring the following:

• If you have private insurance or Medicare, please bring your insurance card with you.
• If you have been referred to us by a physician, please bring your doctor's prescription for your treatment. If you doctor didn't give you a written prescription, please contact us right away, so that we can make arrangements to obtain your doctor's referral by fax before you arrive.
• If you had surgery, please bring a copy of the doctor's report of your operation. If you doctor didn't give you an operation report, please contact us right away, so that we can make arrangements to obtain the report by fax before you arrive, if it's available.
• Please bring appropriate clothing with you for your initial visit. We have complete dressing room and shower facilities for your use. Athletic wear, or loose, comfortable casual clothes are helpful. Gym or walking shoes are also requested. Female patients are discouraged from wearing one-piece leotard type clothes that restrict our access to injured areas.

Thank you for taking the time to complete and bring these items for your initial evaluation. If you have questions or concerns of any kind before you arrive, please give us a call. We look forward to meeting you and to helping you recover your health. See you soon!

(Existing patients, please download and fill out our Patient Satisfaction Survey if you haven't already).

[Printable Version]