New Patient Forms

Click the links below to download the forms you’ll need before your first visit. Fill out all the forms in the first section and at least one in the second. Some people will also need to fill out something in the third section, so be sure to glance through it. Note: Links are underlined in blue, you may need to save them somewhere on your computer in order to print.

First Section: General Intake Forms

These forms are for all new patients. The first sheet contains all the things you’ll need to know in order to prepare for your first visit, and we’ll need the next three in order to get started, so please print them, fill them out, and bring them with you to your first visit.

  1. Welcome
  2. Patient Registration Form
  3. Patient Health History
  4. Privacy Practices

Second Section: Your Condition

These forms tell us how you’re doing. Choose at least one that fits. and as many as you need to describe your condition. Fill them out within a day or two of your first appointment. NOTE: No math required! There’s  a place at the bottom of each form for scoring, but our staff will do that part when you get here.

  1. Arm & Shoulder
  2. Back
  3. Balance
  4. Concussion
  5. Dizziness
  6. Falls
  7. Headache
  8. Hips & Legs
  9. Jaw/TMJ
  10. Neck Index
  11. General Choose this one if none of the options above fit your situation.

Third Section: Special Situations.

If any of the following apply to you, please bring the completed form to your first visit.

Home Health If you are transitioning from Home Health to our clinic, you MUST have already been discharged from Home Health before we start treating you. We’ll need the name of the company and PT who has been coming to your home, as well as your discharge date.

Medicare as Secondary Insurance If you have Medicare but another payer pays first, please fill out this form: Medicare Secondary Payer Questionnaire

Motor Vehicle Accident. If you were in an accident and would like us to bill an automobile insurance company, you must fill out this form. We’ll also need a copy of your accident report and a letter from your lawyer if you have one. We will need this form to be completed before we schedule your first appointment. Motor Vehicle Accident Intake Form

Worker’s Comp. The first step in getting scheduled is for your Worker’s Comp Insurance company or Case Manager to contact us and send us a referral. We will also need a referral from your doctor. We’ll give you a call as soon as we have these two things!