FORMS | ACPT

NEW PATIENT FORMS

Prior to you first visit please read the following information regarding HIPAA and ACPT’s financial policy. You will be asked for a signature indicating that you have read and accept these policies prior to your visit.

HIPAA

Financial Policy

Intake Forms for all New Patients

Intake Information

Consent for Treatment

Past Medical History

HIPAA & Financial Policy Confirmation

Forms related to injury or pain location

If you will be seen for a condition effecting one of these body regions please fill out the corresponding form.

Please be aware that some insurance companies require extra paperwork which is specific to certain policies. If you have one of these policies you will be asked to fill out 1-2 more forms prior to your first visit.

NEW PATIENT FORMS

Intake Forms for all New Patients

Forms related to injury or pain location

Neck (Cervical Spine) or Headache

Middle and Low Back (Thoracic Spine, Lumbar spine)

Headaches

Hip, Knee, Ankle, or Foot

Shoulder, Elbow, Wrist or Hand

Dizziness/Vertigo