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| We want to make your experience with us as comfortable as possible. In order to begin your treatment and expedite your therapist's initial evaluation, please take a few minutes to download, read over, and fill out the forms below and bring them with you to your appointment . |
You will need the free Acrobat Reader in order to download, view and print the forms. Click on the following logo to go to Adobe's Website, to download the latest version of the "Free" Acrobat Reader. |
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To download the forms click on the name of the
form below. |
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The Health History Questionnaire . Please fill out the front page letting us know why you are coming and what other medical issues we need to be aware of. Of the remaining pages, please check the box next to the activities you are having problems with in any way. Use the right hand column to explain any details you wish. |
Notice of Patient Information Practices. Please read and print a copy of the consent form on the fourth page of this Notice that we are required to give you for the Health Care Portability and Accountability Act (HIPAA). |
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 long with the forms listed above, please also bring the following:
- If you have private insurance or Medicare, please bring your insurance card with you.
- If you have been referred to us by a physician, please bring your doctor's prescription for your treatment. If your doctor didn't give you a written prescription, please contact us right away, so that we can make arrangements to obtain your doctor's referral by fax before you arrive.
- If you had surgery, please bring a copy of the doctor's report of your operation. If your doctor didn't give you an operation report please contact us right away, so that we can make arrangements to obtain the report by fax before you arrive, if it's available.
- Please bring appropriate clothing with you for your initial visit; we have private treatment rooms for you to be able to change your clothing. Athletic wear or loose, comfortable casual clothes are helpful. Gym or walking shoes are also requested.
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Copyright © 2010 -2012 Lakeside Physical Therapy Rehab and Sports Medicine | All Rights Reserved | Your Privacy is Protected
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