Logo - Essex Physical Therapy - Physical Therapists
(802) 878-9572
1 Market Place, Suite 33
Essex Junction, VT 05452
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New Patient Forms

To expedite your visit to Essex Physical Therapy, please download the necessary forms below and bring the completed forms with you to your visit. These forms are important in order to save time at your appointment. If you do not have these with you, we will have you complete them before you see the therapist. It is imperative that we have all of this important information at our office as well as your signatures to authorize treatment and allow us to bill your insurance.

If you have any questions when trying to complete the forms, please bring them with you to your appointment and we will be happy to assist you.

All patients should complete a New Patient Information and a Health Intake Form and body part questionaire if applicable.

Click on the forms below to download:

New Patient Information - Standard

New Patient Information – Workers Comp

Health Intake Form

Massage Health Intake Form

HIPAA Privacy Policy Practices

Forms
All patients should complete a New Patient Information and a Health Intake Form and a body part questionaire if applicable.

Body Part Questionnaire

Membership Paperwork

Back Questionnaire

Dizziness Survey

Falls Scale

Headache Survey

Lower Extremity Survey

Lower Limb Questionnaire

Neck Survey

Pelvic Floor Survey

Shoulder Survey

TMJ Questionnaire

Upper Extremity Survey

Personal Training Membership Registration

Pool Membership Registration

Excerise Class Waiver

Contact us if you have any questions about our forms.

 

New Patients - Physical Therapists