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 Questionnaire

Patient Registration Form

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

Cuestionario De Salud Del Paciente

Formulario De Registro De Pacientes

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

Physician Referral Form

Notice Of Privacy Practice

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.

Pain Drawing

Medicare Financial Limitation

Form for Medicare patients.

Dolor De Espalda Índice

Back Pain Index

"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."

Dolor De Cuello Índice

Neck Pain Index

Complete la forma apropiada basada en la localización del problema.

Del brazo, del hombro y de la mano

Shoulder, arm and hand

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.

Dolor Extremidades Inferiores Índice

Lower Extremity Pain Index

Complete la forma apropiada basada en la localización del problema.