Patient Registration Forms

REGISTRATION FORMSThe forms below are provided for patient convenience.  Though completing medical forms and authorizations is not particularly interesting, it is a necessary part of what we do.  Completing them at your own convenience is easier for you and makes your initial visit with us more pleasant.

We will let you know which forms to complete when setting up your initial consultation with Dr. Pensavalle.

NEW PATIENT REGISTRATION PACKET; Print and complete

Registration Forms:

  1. WELCOME to OrthoBalance Physical Therapy Dec 2013
  2. INITIAL INTAKE FORM OrthoBal July 2013
  3. MEDICAL HISTORY FORM OrthoBal July 2013
  4. INFORMED CONSENT FOR PHYSICAL THERAPY OrthoBal July 2013
  5. CONSENT & AUTHORIZATIONS [HIPAA]
  6. MEDICARE BILLING AGREEMENT OrthoBal July 2013
  7. CANCELLATION and NO SHOW POLICIES OrthoBal Dec 2013
  8. NOTICE OF PRIVACY PRACTICES Patient SIGNED COPY OrthoBal July 2013
  9. CONSENT TO TREAT MINOR CHILDREN OrthoBal July 2013

Outcome Measurement Forms:

  1. FALLS EFFICACY SCALE for patients
  2. Lower Extremity Functional Scale
  3. Neck Disability Index Questionnaire
  4. Oswestry Low Back Pain Disability Questionnaire
  5. Pain Disability Index
  6. Shoulder Pain and Disability Index for patients
  7. Upper Extremity Functional Index

Our forms are PDF files. In order to download and print them, you’ll need the free Adobe Acrobat Reader program: iPad/iPhone | Android | Desktop

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