patient forms

A few things to remember before your appointment at Spine & Sport
  • Always arrive 15 minutes early to allow time to get you ready before your appointment
  • Bring all required new patient forms fully completed
  • Bring with you shorts and a t-shirt which is required for the evaluation
  • Payment is due each time of service by cash or check only, we do not accept credit or HSA cards
Effective January 1, 2015: Patients may seek physical therapy services without a physician prescription for 21 days or 10 treatments, whichever occurs first. A prescription is required for all patients covered under Blue Cross Blue Shield, Messa, Medicare, Auto Insurance, or Worker’s Compensation.

  1. Adult Intake
  2. Minor Intake
  3. Re-Evaluation Adult Intake
  4. Re-Evaluation Minor Intake
  5. Medicare Cap Notice
  6. Authorization to Treat a Minor
  7. Subjective Pain Questions
  8. Re- Eval Subjective Pain
  9. Subjective Pain Questions- Child
  10. Lower Body Medicare
  11. Lower Body
  12. Upper Body
  13. Auto & WC Required Information
  14. Notice of Privacy Practices
  15. Medical Record Authorization Form
  16. Hotel Suggestions
  17. Prescription Form