New Patient Forms

whAT TO BRING TO YOUR FIRST VISIT:

1. Completed forms
2. Insurance card
3. Photo identification
4. Referral from your doctor (optional)

What To Wear:

Comfortable clothing such as workout clothes or anything you would wear to the gym or a physically active class.

Before arriving for your first appointment at Specialized Physical Therapy, please fill out these forms:

  1. New Patient form

  2. Functional Scale form

  3. HIPPA form

Please bring or email these forms fully completed to your initial physical therapy visit.

If you choose instead to fill out the new patient forms at our office, please arrive 20 minutes prior to your appointment to complete the required paperwork.

If you have any questions please feel free to contact us at 714-838-6999 or email us at info@specializedpt.com 

FORMS:

  1. New Patient Form

2. Choose the functional scale new patient form that is most applicable to your injury by clicking on the proper box below, then download, print, and complete that form.  (Our forms are PDF files. To download and print the forms, you’ll need the free Adobe Acrobat Reader program.)

foot, leg, hip (lower extremity)

hand, arm, shoulder (upper extremity)

Neck

Back

3. HIPPA Form

Medicare Patient Forms:

Medicare Patients please fill out these forms in addition to the new patient forms.