Patient Forms

Listed below are the forms you will need to complete prior to receiving therapy services at our clinic. Form 1, Privacy Notice, is your information only. Forms 2-4 can be printed, completed, and brought with you to your first appointment. Complete form 5 if services relate to a worker's compensation claim. Complete form 6 if services relate to an auto accident. Complete form 7 if services relate to a personal injury claim.

Additionally, please bring the following information with you to your first appointment:

• Your insurance card(s)
• A list of all over the counter as well as prescribed medications including dosages and the frequency that you take each medication.
• Your referral/script if your physician has not already given this to us.

1. Privacy Notice
   This is for your information only. You do not need to bring a copy in with you if you have signed the Privacy Act Acknowledgement form.
2. Patient Registration Form
   You will need your insurance information to fill this out.
3. Release of Info/Financial Policy (needs signature)
   This form discloses medical records, information, and documentation in order to process insurance claims.
4. Medical History Form
   To aid us in the selection of a proper treatment program we ask that you complete the following health screening.
5. Work Comp Form
   This form is needed, in addition to the above forms, if your injury was work related and your claim will be paid by worker's compensation.
6. Auto Accident Form
   This form is needed, in addition to the first four forms, if your injury was due to an automobile accident.
7. Personal Injury Form
   This form is needed, in addition to the first four forms, if your injury was due to a personal injury.

Miscellaneous Forms

Aquasizer (if prescribed)
This is a brief description of what you will need and what to expect when receiving hydrotherapy.

[Printable Version]