PATIENT forms

thinking ahead

When you head out the door for your first appointment, there are a few items we ask you bring along – your insurance card as well as your driver’s license or photo ID. Also, if you were referred to us by a physician, please remember your prescription.

No one likes filling out form after form at a doctor’s office. So why not finish them ahead of time? Print these documents out, then either bring the completed forms with you to your first appointment, or simply fax them to our office.

Patient forms

Medical History Form Checklist 2016
Medical History Spanish
Pain Diagram
Pain Diagram Spanish
Source of Referral

Your First Step Towards physical health Starts Here :

After coming here three times a week, every week for six months – you’re part of their life. And they’re part of your life.

Patient

Diane Beideck

Everyone was really welcoming. It was just an environment where you could jump in and learn.

Student

Ricardo Whittaker - Ithaca College

I need a physical therapist that is going to think about what I do every day for a living.

Patient

Susan Reno

I had a little bit of low confidence. And my CI was the one who helped me build that confidence.

Student

Tiffany Bader -  Central Michigan University

They’re concerned about your concerns. You’re not just a number – you’re a human.

Patient

Matt Mamoone

I felt like I was another therapist in the clinic. I wasn’t just a student.

Student

Tom Maving - Nazareth College