Regain Your Peak Performance

Patient Forms

In order to begin treatment and expedite your therapist’s initial evaluation, we would appreciate if you would take a few minutes to read over, print and fill out the appropriate forms below. Please bring the completed forms with you to your first appointment.

General New Patient Forms:

Please read, print and sign the following new patient forms:  

• New Patient Information Form
• Patient Health Questionnaire

Also, print, read, and initial the financial/insurance coverage packet: 

• PPO, Cash, or Med-Pay 
• Medicare 
   

Patient Intake Surveys:

Please fill out one of the following FOTO forms most related to your injury. 

• FOTO Arm/Hand
• FOTO Shoulder
• FOTO Upper Body - Neck, Thoracic Spine, Ribs
• FOTO Lower Back
• FOTO Hip/Pelvis/Upper Leg
• FOTO Knee 
• FOTO Foot/Ankle/Lower Leg
• TMD Index  - Disability in the TMJ (Jaw area)

Patient Discharge Forms:

When your therapy is complete we would appreciate your honest feedback. Feel free to submit this form electronically, through the mail, or in person.

• Patient Satisfaction Survey 

Please become aquainted with the Notice of Patient Information Practices information. This informs you of the legal uses and disclosure of patient information according to the Health Care Portability and Accountability Act (HIPAA.)