Client Forms to fill out before your appointment

Here are some forms that you can down load and fill out before your appointment.

In addition to saving time, you will be able to have an unhurried time to fill it out completely. Please arrive at the first appointment with these filled out if you can.

Clicking on the underlined form name will show the form to you, mouse over the form and it will give you the option (in the lower right side) to download (or print directly) the form to your computer in PDF form. 

You can then print and fill it out.

These first 2 forms are used with all clients and patients, please download and print them if you can, so that you will have them when you come for your first session or evaluation:

BODY FORM TO SHOW WHERE YOUR PAIN IS   Please indicate where you feel pain, or discomfort and indicate the type of discomfort as well as you can.

SHORT HISTORY FORM (FOR MOST CLIENTS)  All clients will need to fill this form out, bring it with you or I also have them at the office.

 

The following are used when auto insurance or workers comp are being used.

If you are not going to see your doctor before coming in for an evaluation, I will need to send one to your doctor, so please have the doctors FAX number for me, so that I can fax the script to the doctor prior to your appointment. You could do this step for me if you have the ability to FAX.

I may also need an "OK" from your doctor if there are more complex problems with your health, the same form can be used.

PRESCRIPTION FORM FOR DR TO REQUEST TREATMENT  I must have a prescription from a DR or DC if I will be billing to an insurance company. I can only bill mostt Auto insurance, Workers Comp and ChampVA. Very rarely will any health insurance cover my services.

LONG HISTORY FORM FOR AUTO INSURANCE, WORKERS COMP AND COMPLEX CASES  This form is long and detailed and is a must if you have been in an accident. It is also helpful to me if you have a long or complex medical history

PATIENT DATA FOR INSURANCE BILLING FORM  I must have this form to bill your insurance, you will need the insurance companies information, case # and the adjusters name and direct phone if possible

 

If you have CHAMPA, please bring a completed  Patient data form if possible. I will need this information to send the bill to them.

 

 

 

 

 

 
 

© Copyright 2017 "Advanced Bodywork & Massage" Myofascial Trigger Point Therapy . All rights reserved.