New Patient Forms:

Print and complete these forms on your time. You can either fax or email the forms and your doctor’s referral to FYZICAL of Jacksonville prior to your first visit, or you can bring them with you to your first visit.

Fax number: (904) 223-2365
Email: therapy@inmotionjax.com or jaxpt@fyzical.com

All New Patients: please select, print and fill out both of the following forms:

New Patient Intake Form

New Patient Payment Authorization Form

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Please select, print and fill out one of the following pain questionnaires:
(If you are being treated for difficulty with walking or balance, please fill out the leg pain questionnaire. Your therapist will then review the questionnaire and possibly do further testing during your evaluation.)

Back Pain Questionnaire

Neck Pain Questionnaire

Shoulder, Elbow, Arm, Wrist and Hand Questionnaire

Hip, Knee, Leg, Foot and Ankle Pain Questionnaire

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Medicare Patients: please select, print and fill out the following form:

Medicare Disclaimer Form

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United Healthcare Patients: please select, print and fill out the following form:

United Healthcare Patient Summary Form

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Patients who are Minors (under 18 years old): Parent/Guardian please select, print and fill out the following form:

Parental Consent Form

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Additional Forms, Notice of Privacy Practices, Adobe Reader Download:

Medications List

Patient Survey

Notice of Privacy Practices

FREE Adobe Reader Download