• Intake Form

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Examples: Referred by a doctor, referred by friend/colleague/family, advertising (brochures, banner, etc.), by chance/walk in, by employee staff, internet search, returning patient
  • Confidential Health History Form

  • Authorization for Submission & Direct Payment

    Please fill out form ONLY if we bill directly to your insurance company. List can be found in FAQ.
    If "No" or "will submit myself" please skip to the next section
  • Date Format: MM slash DD slash YYYY
  • Please print out your FULL name.
    Thank you kindly for your cooperation with this matter.
  • Visual Analog Scale

  • Referring to the drawings below, please indicate where you are experiencing pain by describing the area of injury, and the scale number for your current level of pain. Please list where you are feeling the pain (I.E. neck, back, shoulder, etc.).

  • Please refer to above picture for the answer to this question.
  • Please refer to above picture for the answer to this question.
  • Please refer to above picture for the answer to this question.
  • Motor Vehicle Accident Information Sheet

  • Date Format: MM slash DD slash YYYY
  • Consent Forms

  • Physiotherapy Consent
    Please input your FULL NAME here!
  • Massage Therapy Consent
    Please input your FULL NAME here!