Forms

Prior to your first visit, we ask that you download and complete the Patient Evaluation Intake and the appropriate Body Questionnaire Forms. Please bring the completed forms with you to your first appointment. (If you are unable to, please plan to arrive 15 minutes prior to your scheduled time to complete paperwork)

Patient Evaluation Intake

Please choose from below the form for the body area that is your chief complaint
Neck Questionnaire
Shoulder and Upper Extremities Questionnaire
Back Questionnaire
Hip_Outcome_Scale
Lower Extremities Questionnaire
Dizziness Questionnaire

HIPAA Privacy Policy

(NOTE: you are not required to print this policy. The Privacy Policy Signature Page is included on the registration forms.)

Additional Miscellaneous Forms

Consent for Treatment of Minor

Please be sure to bring the following items with you to your first appointment:

  • The completed forms listed above.
  • Comfortable clothing as noted below:
    • For low back pain or lower extremity problems, please bring shorts and a t-shirt.
    • For females with back, neck, and/or upper extremity problems, please bring shorts and a halter-top, bathing suit top, or one-piece backless bathing suit. Note that a sport back jog bra obscures viewing of the shoulder blades and is not recommended.
  • Your current insurance card and a photo ID
  • A method of payment (i.e., checkbook, credit card, etc.).

 

Cancellation Policy

Patients are seen, at Movement Systems Physical Therapy, by appointment only.  Scheduling is based on a first come, first served basis.  It is advisable for you to schedule your appointments in four to six week intervals.

In the event you need to cancel an appointment, we require at least 24 business hours notice (Monday appointments MUST be canceled no later than 3pm of the prior Friday.). Your appointment time is very important to us.  If we do not get at least 24 business hours notice of your cancellation, or you do not arrive for your scheduled appointment (no show) you will be assessed a $100 fee.

We realize that emergencies do occur – late cancellation due to illness or family emergency is excluded from this policy.