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