Patient-Registration | Primacare Physical Therapy

Patient Registration Forms

We encourage you to complete the 'Patient Registration' and 'Patient Questionnaire' forms at your convenience for your first visit

Coverage for Your Medical Needs

Patient Registration Form

Patient Questionnaire

Basic demographics and insurance information and health questionnaire forms for all patients.

Formulario De Registro De Pacientes

Cuestionario De Salud Del Paciente

Basic demographics and insurance information and health questionnaire forms for all patients in Spanish

Notice Of Privacy Practice

Physician Referral Form

Please bring the Physician note or Referral signed by the physician with you on your first visit. It is possible that we may be unable to see you without a referral. You can print this Physician Referral Form and have the physician sign it.

Medicare Financial Limitation

Pain Drawing

Form for Medicare patients.

Back Pain Index

Dolor De Espalda Índice

"If you are having a problem in one of the body regions listed in the column, click on that region, print off, and fill out the form and bring it with you. Please do this within 24 hours prior to your appointment."

Neck Pain Index

Dolor De Cuello Índice

Complete la forma apropiada basada en la localización del problema.

Shoulder, arm and hand

Del brazo, del hombro y de la mano

If you are having a problem in one of the body regions listed in the column, click on that region, print off, and fill out the form and bring it with you. Please do this within 24 hours prior to your appointment.

Lower Extremity Pain Index

Dolor Extremidades Inferiores Índice

Complete la forma apropiada basada en la localización del problema.