Consultation Form (LIVE)

Physical Therapy Consultation Form

Let's see if Physical Therapy would be a benefit to you and your health! Fill out this brief form, and we will be in touch shortly.
Full name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
What injury or issue is bringing you to consider physical therapy?*
Please describe how you may have obtained this injury and list any complaints that you may have.*
Have you been seen by a doctor or another physical therapist for this issue before?*

YesNo
If you selected "Yes" please describe the treatment you received and if/how it helped. If you selected "No" simply put "N/A."*
Do you have any concerns about physical therapy and possible treatments?*
How are you planning on paying for treatment?*

InsuranceSelf-Pay
Please list your primary and, if applicable, your secondary insurances. If Self-Pay please write "N/A."*
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Health Questionnaire*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel fain in your chest when you do physical activity?
n the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials*

Clear
Attendance Policy
All cancellations must be received at least 24h before your physical therapy session in order to avoid being charged. Clients who do not cancel with 24h notice will be charged the $50 late cancellation and no-show fee. Club Rehab Physical Therapy understands that emergencies happen. We provide every client with one free grace for a short-notice cancellation. You will not be charged for your first cancellation with less than 24h notice. Subsequent short notice cancellations and no-shows will be charged. All cancellations must go through the front desk and not the physical therapists themselves.

No shows are not eligible for the free cancellation.
Initials*

Clear
Billing Policy
I hereby authorize Club Rehab Physical Therpay to securly store my credit card information and run the card for the estabilished $50 if I do not give proper advanced notice in cancelling appointments per Club Rehab Physical Therapy's Attendance Policy.
Initials*

Clear
Signature*

Clear
Date

JourMoisAnnéeHour MinutesAM/PM Option
Additional Comments
Should be Empty:

Physical Therapy Consultation Form