Hands on care of sports injuries.

PATIENT FORMS

 

The forms below are provided for the convenience of our Back In Motion patients.  To save time in our office, please download, complete and bring them to your office visit. These forms will be integrated into our electronic medical records system. You will need the free Adobe Acrobat reader to view the documents. If you need to download a copy, you can do so by clicking on the Acrobat icon.Adobe.com

NEW PATIENT, NEW CONDITION, AND RE EXAM FORMS
Please print and fill out the form(s) that are appropriate for your needs and bring them with you to your office visit

New Patient Forms

New Patient Forms for Massage Therapy Appointment

REGION FORMS
If you are experiencing neck or mid-lower back pain, please select and fill out the appropriate form below as it applies to your specific regional pain or discomfort

Neck Pain Questionnaire

Mid-Lower Back Pain Questionnaire

ADDITIONAL FORMS
If we are treating a patient under 18, our clinic requires permission from a parent or guardian

Consent to Treat a Minor

If you have recently been in a motor vehicle collision  or have experienced a work-related injury, you are required to complete one of the following

Motor Vehicle Collision

Workmans Compensation

Our Billing Manager will direct you to this form if your insurance company denies your claim and states “only the patient has the right to appeal denials”

Designation of Authorized Representative

If you wish to take medical redords from the clinic, you must fill out this release

Authorization for Disclosure of Health Information