Intake Forms

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Required:

Patient Intake – general information to get you started.

HIPAA Notice of Privacy Practices – please read.

HIPAA Acknowledgement – confirmation of receipt of notice of privacy practices.

HIPAA Release of Information – authorization to use/disclose records if necessary.

Choose One:

Back Index – information about how your back condition affects your everyday life.

Neck Index – information about how your neck condition affects your everyday life.

Arm, Shoulder, Hand – DASH (Disabilities of the Arm, Shoulder or Hand)

Hips, Legs, Knees, Ankles, or Feet – LEFS (Lower Extremity Functional Scale)

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