Patient Intake Form

Please feel free to complete our Patient Intake Form below before your first visit or if you are doing distance therapy.

  • General Information

  • Billing Information

  • WCB/MPI Information

  • Referral

  • (Check all that apply)
  • Medical History

  • (Check all that apply)
  • (if so, please list)
  • This spot is specifically held for you. Late cancellations prevent others from attending, delays your recovery and opens time in the therapists working schedule. If you cancel an appointment within the 24-hours, or do not come to an appointment without notice, the following actions will be taken:

    First Late Cancellation/No-Show Second Late Cancellation/No-Show Third Late Cancellation/No-Show
    Warning with reminder about cancellation policy $40 cancellation fee will be charged to you and payment is due before treatment can continue We will no longer continue with treatment, and you will be discharged.

    A 24 hour notification is required to cancel or reschedule an appointment. I understand I will be responsible for a $40.00 fee if insufficient notice is provided. Treatment will not continue until payment is remitted. My signature acknowledges that I accept and understand the above information.

  • Use your mouse to sign, or your finger if you are on a phone or touch device.
  • This field is for validation purposes and should be left unchanged.