Forms
Listed below are the forms you will need to complete prior to receiving therapy services at our clinic. Form 1, Privacy Notice, is for 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
(76K)
This is for your information only. You do not need to bring a copy in with you; however, you will be asked to acknowledge receipt of this information.
- Patient Registration Form (156K)
You will need your insurance information to fill this out. - Release of Info/Financial Policy (132K)
You will need your insurance information to fill this out. - Medical History (521K)
To aid us in the selection of a proper treatment program we ask that you complete the following health screening. - Work Comp Form (91K)
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 (105K)
This form is needed, in addition to the first four forms, if your injury was due to an automobile accident. - Personal Injury (89K)
This form is needed, in addition to the first four forms, if your injury was due to a personal injury.