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Patient Info

Forms

On your first visit please bring these items with you:

  1. Photo identification
  2. Insurance card
  3. Prescription from your doctor
  4. The following three forms (please fill out before your first visit)

Patient Information Form

Policies And Patient Responsibilities

Notice of Patient Information Practices

     5.  Choose the Outcome Report as requested by our office.

Berg - Initial

Dizziness Handicap Inventory - Initial

Foot and Ankle Ability Measure - Sports Subscale - Initial

Hip disability Osteoarthritis Outcomes Score - Initial

Knee injury Osteoarthritis Outcomes Score - Initial

Lower Extremity Functional Scale - Initial

Lymphedema Life Impact Scale (v2) - Initial

Modified Falls Efficacy Scale - Initial

Modified Oswestry Low Back Pain - Initial

Neck Disability Index Questionnaire - Initial

Pelvic Floor Distress Inventory Short Form 20 - Initial

Upper Extremity Quick DASH - Initial

If you would like our team to coordinate care with another physician practice please complete the form below to authorize release of your medical records

                 HIPAA Authorization Form

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