Patient Forms
Listed below are the forms you will need to complete prior to receiving therapy services at our clinic. Form 1, Privacy Notice, is your information only. Forms 2-4 can be printed, completed, and brought with you to your first appointment. Complete form 5 if services relate to a worker's compensation claim. Complete form 6 if services relate to an auto accident. Complete form 7 if services relate to a personal injury claim.
Additionally, please bring the following information with you to your first appointment:
- Your insurance card(s)
- A list of all over the counter as well as prescribed medications including dosages and the frequency that you take each medication.
- Your referral/script if your physician has not already given this to us.
- Privacy
Notice
This is for your information only. You do not need to bring a copy in with you if you have signed the Privacy Act Acknowledgement form. - Patient Registration Form
You will need your insurance information to fill this out. - Release
of Info/Financial Policy
(needs signature)
This form discloses medical records, information, and documentation in order to process insurance claims. - Medical
History Form
To aid us in the selection of a proper treatment program we ask that you complete the following health screening. - Work Comp Form
This form is needed, in addition to the above forms, if your injury was work related and your claim will be paid by worker's compensation. - Auto
Accident Form
This form is needed, in addition to the first four forms, if your injury was due to an automobile accident. - Personal Injury Form
This form is needed, in addition to the first four forms, if your injury was due to a personal injury.
