Patient Forms

Please take the time to print out and complete all the forms in advance. Your responses are essential, not only for streamlining the medical intake process and managing your case, but most importantly to help guide our practitioners to the root of your problem. In addition, we want to ensure your session is spent receiving our healthcare services and not filling out our paperwork. It is recommended you arrive 10 minutes before your first appointment so our staff can review your insurance benefits with you. Please bring your insurance card if applicable. Thank you in advance for completing the forms prior to your appointment.

Insurance based traditional PT:

New Patients/Returning patients

• New Patient Intake Form (5 pages) or
• Returning Patient Intake Form (2 pages)
• TDN Consent Form (1 page)

Also please complete the appropriate form(s) depending on the area(s) of your condition.

• Back Index
• Neck Index
• DASH (shoulder, elbow, wrist, hand)
• LEFS (hip, knee, ankle, foot)

Private pay programs:

TNE (Therapeutic Neuroscience Education) Program patients

• TNE Admin Intake
• TNE Medical Intake
• FABQ
• Tampa

TDN (Trigger Point Dry Needling )Tune-Up patients

• TDN Tune-Up Intake and Consent Form

Please download the following if you want to request that your medical records be sent to another healthcare provider:

• Records Release Request to PACE-WEST
• Records Release Request to MD

Please download the following for your records:

• Notice of Privacy Practices