Patient Forms

Patient details, date of birth, contact information, insurance, and referring physician. This is the first form we need so we can keep complete records and bill your insurance accurately.

Authorises Dynamic Physical Therapy to bill your insurance directly and receive payment on your behalf, and sets out your responsibility for co-pays, deductibles, and non-covered services.

Confirms you have received the Notice of Privacy Practices and had the opportunity to review it, as required by the Health Insurance Portability and Accountability Act.

Every medication you are currently taking, with strength, dosage, and what it is for. Your therapist reviews this before your evaluation, so please bring it completed.

Our cancellation and no-show policy. Reading and signing this keeps appointment availability fair for every patient on our schedule.

Short screening questionnaire completed before EMG/NCV studies, musculoskeletal ultrasound, or other diagnostic testing.

The full HIPAA notice describing how your medical information may be used and disclosed, and how you can access it. For your records - no signature required.

For Medicare patients only. If Medicare may not cover a physical therapy service, this notice explains your options and the potential cost before we proceed.

For accident and personal-injury cases. Directs your attorney or settlement to pay Dynamic Physical Therapy directly out of any monies recovered on your behalf.