Patient Intake Form

Patient Intake Form
Please note, this form is secure but it is not HIPAA-compliant. If you would rather print and bring this form with you to the appointment, click here.
Address *
Address
City
State/Province
Zip/Postal
Sex *
Would you like to be notified via email of Physical Therapy updates and notifications? *
Were you Referred? *
Is your condition due to an auto or work-related accident? *
Did you file a claim?

Treatment Consent

A licensed Physical Therapist will perform your evaluation and treatments. A variety of treatment techniques may be performed, as allowed under the physical therapist’s scope of practice. I hereby consent to Physical Therapy Evolution providing care and treatment for my condition.

HIPAA Privacy Rule Acknowledgement

I acknowledge that I have read the HIPAA Privacy Notice, accessed online at www.hhs.gov/sites/default/files/privacysummary.pdf. I understand that I may receive a copy of this notice upon request at any time, and that I may inquire at Physical Therapy Evolution with any questions I may have regarding the Notice of Privacy Practices.

Cancellation and No-Show Policy

If I am unable to keep my appointment, I understand that a 24-hour notice is required (if my appointment is on a Monday, I understand cancellation notice is required on or before the preceding Friday), or I will incur a full appointment charge. We appreciate your understanding of this policy.

Checkboxes *