• 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

  • (Please answer NO or list if any)
  • Authorization for Submission & Direct Payment

    Please fill out form ONLY if we bill directly to your insurance company. List can be found in FAQ. Please put N/A if not applicable.
    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

  • On the drawings below, please indicate where you are experiencing pain by describing below what areas hurt, and where on the scale your pain sits. Please list where you are feeling the pain (I.E. neck, back, shoulder, etc.) and on the scale from no pain to unbearable pain please place an X that best describes the severity of the pain you are feeling.

  • Please refer to above picture for the answer to this question.
  • Please refer to above picture for the answer to this question.
  • Consent for Physiotherapy

  • Please input your FULL NAME here!
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.