Patient Forms

New patients can save some time during their first visit by printing and completing the following forms:

Patient Forms:

New Patient Form HIPAA Form Policies Form

Appointment Reminder Form Medical Questionnnaire Form Orthotic Agreement

Medicare Related Forms:

Medicare Advanced Beneficiary Notice Form

Medicare PT Fees

The following forms are for special circumstances:

Motor Vehicle Lien Form Referral Waiver Form

Release of Records Form Pool Release of Liability Form

For your information:

Patient Bill of Rights

Questionnaires:

Berg Balance Scale Disabilities of the Arm, Shoulder, and Hand (DASH)Lower Extremity Functional Scale (LEFS)Lysholm Knee Questionnaire

Neck Disability Index (NDI)Optimal Instrument Upper Extremity Functional Scale (UEFS)Oswestry Back Disability Index

Shoulder Pain and Disability Index (SPADI)Patient Specific Functional Scale

READY TO GET BACK IN THE GAME?

Request an Appointment today by calling (800) 346-9153 or use our online form.

Request Appointment

Get Inspired

Uncategorized

April 15, 2023

The Facts About Hypermobility

Have you ever seen those talent competitions where a contortionist can sit on their own head? What about…

Michael Velsmid

Love0

concussion

Uncategorized

October 15, 2021

Concussion Blog Part 3 – Headaches (HA) and Whiplash Associated Disorder (WAD)

Following a concussion it is not uncommon to experience a headache. Here are the various types of headaches…

gb-bossm

Love0

concussion comeback

Uncategorized

October 14, 2021

The Winding Road of Returning to Activity After A Concussion

By: Michael Geiger, PT, DPT, ITPT In our most recent blog post in our concussion series, we introduced…

gb-bossm

Love0