Patient Forms

The link below will provide you with our patient forms. Please print these out and complete them before you come in for your first visit.

All patients please fill out:

• Patient Information Form
• Notice of Privacy Rights & Acknowledgement

Direct Access:

• NYS Direct Access Form - if you are coming to physical therapy without a prescription from your doctor.

All spine patients please fill out:

• Duffy-Rath Questionnaire® - for back and neck patients to fill out the day of their 1st (and each follow up) appointment

All shoulder/elbow/wrist patients please fill out:

• Upper Extremity Functional Scale

All hip/knee/ankle patients please fill out:

• Lower Extremity Functional Scale

If you have Medicare, please fill out:

• Notice of Exclusions from Medicare Benefits

If you have MVP Gold, please fill out:

• Notice of Exclusion from MVP Preferred Gold Benefits

All patients attending physical therapy for Vertigo or dizziness please fill out:

• Vestibular History Form