| PATIENT FORMS |
Want to take care of the necessary paperwork before you arrive? Download
and fill out the forms(1-4) below, then simply bring them with you to your first
appointment.
The receptionist and physical therapist will go over all the forms with you, so
fill them out to the best of your ability.
and fill out the forms(1-4) below, then simply bring them with you to your first
appointment.
The receptionist and physical therapist will go over all the forms with you, so
fill them out to the best of your ability.
1. Patient Form This form provides us with your personal and insurance information.
Richmond Office Form
Ashland Office Form
2. Medical History This form provides us with your a detailed history of your medical background and
information regarding your current problem.
Richmond Office Form
Ashland Office Form
3. Body Specific Questionnaire (CHOOSE ONE) These forms provide us with further detailed
information directly related to the body part we will be
treating. Forms apply to both offices.
A. Arm, Shoulder, Hand
B. Lower Extremities (knee, ankle, foot)
C. Back
D. Neck
4. Patient Responsibilities Outlines our office polices and patient
responsibilities.
Richmond Office Form
Ashland Office Form
5. Notice of Privacy Practices (TO READ ONLY - DO NOT PRINT)
Richmond Office Form
Ashland Office Form
2. Medical History This form provides us with your a detailed history of your medical background and
information regarding your current problem.
Richmond Office Form
Ashland Office Form
3. Body Specific Questionnaire (CHOOSE ONE) These forms provide us with further detailed
information directly related to the body part we will be
treating. Forms apply to both offices.
A. Arm, Shoulder, Hand
B. Lower Extremities (knee, ankle, foot)
C. Back
D. Neck
4. Patient Responsibilities Outlines our office polices and patient
responsibilities.
Richmond Office Form
Ashland Office Form
5. Notice of Privacy Practices (TO READ ONLY - DO NOT PRINT)
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RICHMOND
ASHLAND
P H Y S I C A L T H E R A P Y
Orthopedic and Sports Physical Therapy