Patient Forms

PLEASE CANCEL WITHIN 24 HOURS DURING BUSINESS HOURS IF YOU ARE UNABLE TO KEEP YOUR APPOINTMENT. We appreciate your cooperation in avoiding no-shows as we have other patients who would be grateful to take your appointment time. Thank you!!

Be sure to bring the following to your evaluation appointment:

• Legal photo ID or driver's license
• Insurance card(s)
• Prescription for therapy from your physician
• Your calendar of commitments so we can schedule future appointments
• List of surgeries, prescription and over the counter medications

Please print, complete and bring the following forms with you:

• Medical History Form
• Episode of Care
• Missed Visit Policy
• Authorization for Release of Private Health Information
• HIPAA Consent
• General Consent
• Demographic Sheet

For Your Records:

• Notice of Privacy Practices

Ladies only - Pelvic Patients please print:

• Pelvic History
• Pelvic Functional Outcome Measure
• Female Genitourinary Pain
• Missed Visit Policy
• Authorization for Release of Private Health Information
• HIPAA Consent
• General Consent

Men only - Pelvic Patients please print:

• Pelvic History
• Male Genitourinary Pain
• Missed Visit Policy
• Authorization for Release of Private Health Information
• HIPAA Consent
• General Consent

For Your Records:

• Notice of Privacy Practices

*Medicare patients only: please print, complete and bring this form as well.

• Medicare Patients (Medicare patients only)

Functional Outcome Measure Forms:

We will advise each patient which of these forms are needed to print, complete and bring to the evaluation appointment. New insurance regulations require some of these forms to be completed.

• Form #1 - Back
• Form #2 - Neck
• Form #3 - Knee/Leg/Balance
• Form #4 - Shoulder/Arm
• Form #5 - Vestibular/Vertigo
• Form #6 - Jaw
• Form #7 - Lymphedema (CDT)