Patient Intake
FIRST PHYSICAL & FUNCTIONAL REHABILITATION
Patient Name
*
First & Last
Social Security Number
*
Social Security Number
Type of Service Requested (Select All That Apply)
*
Appointment & Facility Policies
Patient Agreement
Authorization for Release of Medical Records
Patient Agreement
Request Copies of:
Authorization for Text Message (SMS) Communications
Patient Agreement
Patient Name
*
First & Last
Signature
*
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Next
Consent to Physical Therapy
Physical Therapy Patient Agreement
Patient Name
*
First & Last
Signature
*
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Next
Consent to Massage Therapy
Massage Patient Agreement
Patient Name
*
First & Last
Signature
*
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Next
Consent to Acupuncture Treatment
Acupuncture Patient Agreement
Arbitration Agreement
Acupuncture Patient Agreement
Patient Name
*
First & Last
Signature
*
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Next
Submit
Submit
Should be Empty: