New Patient Forms

Complete these forms at your leisure and either fax them along with your doctor’s referral to In Motion Physical Therapy prior to your first visit or bring them with you on your first visit.

Our fax number: 904.223.2365

Forms for all new patients to fill out:

	Patient Intake Form
	Medical History
If appropriate, fill in one or more of these Pain Questionnaires:
	Back Pain Questionnaire
	Hip, Knee, Ankle, or Foot Pain Questionnaire
	Neck Pain Questionnaire
	Shoulder, Elbow, Wrist or Hand Pain Questionnaire

Please also complete the following form if applicable:

Medicare Patients:

Medicare Disclaimer

United Health Patients:

United Patient Health Questionnaire

Self Pay Patients:

Self Pay Disclaimer

For those patients who are minors (under 18 years old):

Parental Consent

   Notice of Privacy Practices

Our policy at In Motion Physical Therapy is to begin your treatment series within 24 hours of your contacting our office to schedule an appointment. However, all insurance authorization and verification must be completed, as required by your insurance company, prior to your first visit.

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