East Sacramento Physical Therapy

Phone: (916) 457-8802
Fax: (916) 457-7609
Quality Care with a Personal Touch
Patient Forms




When possible, patients are asked to complete and submit the following form(s) in advance to their first appointment.  Because some therapists require pre-certification or authorization from insurance carriers, patients are urged to fax the completed form(s) to us at 916-457-7609.  By doing so, our business office staff may obtain authorization and/or to confirm eligibility resulting in less wait prior to your initial visit.



For most Patients:

Patient_Info___Insurance_Form


Patient Informed Consent


Patient_History_Form_1

Patient_History_Form_2 

Pediatric_Patient_Forms


 Spanish_Forms 




For Patients with Pelvic Floor Dysfunction:

Pelvic_Questionaire

PFDI_FEMALE

PFDI_MALE



Other Forms:

Notice of Privacy Practices

Acknowledgement of Receipt of Privacy Practices

Directions.pdf
267.2







For your information, there may be additional forms needed which will be provided at your first appointment.  If you have immediate questions or concerns, or if you need assistance with which forms apply to you or the patient, please call or email us today.