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