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  • Let's Get Started!

    Your Personal Health Intake Questionnaire

  • How Can We Help You Today?

  • Select Your Service*

  • Not sure which option is right for you? Choose Initial Evaluation for guided support, or Home Exercise Program (HEP) if you prefer independent direction.

  • HEP ($65) – Customized digital exercise plan for independent guidance.
    Initial Evaluation ($125) – Live video assessment with diagnosis and personalized progression.
    Follow-Up ($95) – For patients who have completed an Initial Evaluation.
    3-Month Premium ($435) – Long-term structured plan with ongoing support.

  • Reminder: HEP services are available to all locations. However, telehealth services are currently available only to patients physically located in Oregon or California.

    We encourage you to start your personal HEP today!

  • Have You Completed an Initial Telehealth Evaluation with PTConnect?*

  • Follow-Up Telehealth Sessions are available only after completing an Initial Telehealth Evaluation. Please select Initial Telehealth Evaluation or an alternate option.

  • Have Your Previously Purchased a PTConnect HEP*

  • Please use the same email where you received your original HEP access code to avoid the confusion of multiple medical profiles.

  • Basic Information

  • Format: (000) 000-0000.
  • Gender*

  • Injury & Condition Details

  • Body Region(s) Seeking Treatment (Select all that apply)*
  • Prior Treatment for This Condition?*
  • History of Surgery?*

  • Pain & Safety Screening

  • Numbness, Tingling, or Weakness?*

  • Medical Records

    (Optional)
  • Are there any additional findings tied to your current condition/injury that you would like to share?
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  • Medical History

  • Chronic Conditions (Select All That Apply)*
  • Are you pregnant or postpartum? (if applicable)*
  • History of Falls?*
  • Activities Nearly Impossible to Complete?*

  • Safety & Telehealth Screening

  • Loss of bowel or bladder control?*
  • Numbness in groin or saddle region?*
  • Recent major trauma with inability to bear weight?*
  • Chest pain with exertion or unexplained shortness of breath?*
  • Sudden unexplained weakness in arm or leg?*
  • Pain level 9-10 and not manageable?*

  • For safety reasons, based on your Safety & Telehealth Screening responses, certain symptoms may require urgent medical evaluation before telehealth services can be provided.

    If you are currently experiencing severe symptoms, worsening neurological changes, or loss of bladder or bowel control, please seek immediate medical care.

    We will contact you shortly to review your responses. Please check your email for next steps.

  • Consent to Services

  • I hereby consent to receive physical therapy services through PTCONNECT, including but not limited to a preliminary assessment/evaluation and ongoing treatment, delivered either via telehealth or other remote methods under PTCONNECT’s clinical supervision. Treatment in this context includes prescription, delivery, and use of a Home Exercise Program (HEP). I consent to the recommended HEP treatment plan and intend this consent to cover the full course of treatment for my current condition, as well as any related conditions for which I seek care.

    I understand that while PTCONNECT provides the HEP and instructions regarding my care, I am responsible for performing the HEP on my own, and PTCONNECT has no control over how or when I carry out these exercises. I agree to follow the HEP to the best of my ability and understand that I may discuss any concerns or difficulties with PTCONNECT. I acknowledge that: "Telehealth delivery of therapy may involve limitations such as dependence on internet connectivity, privacy concerns, and potential technical disruptions." "I am responsible for ensuring a private and safe environment during all remote sessions and for maintaining the confidentiality of any shared platform or device." "I may withdraw my participation or decline any component of therapy—including the HEP—at any time without affecting my future care rights" (withdrawal and reimbursement policies my apply). By signing below, I confirm that I have read, understand, and agree to the contents of this consent form. I also understand that no guarantees have been made regarding outcomes of the therapy or my completion of the HEP.

  • Date*
     - -

  • Submission

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