Adult Evaluation

What Do I Bring to the Initial Evaluation

To view the forms, simply click on the name of the file to open it (Adobe Acrobat Reader 4.0 or above required). You will then have the opportunity to print the file if desired.

Forms not submitted online should be printed, filled out, then sent via fax/mail, or presented at the time of your visit.

• Insurance Card
• Prescription/ Physician’s Order Form for evaluation (CLICK HERE)
** IN ORDER TO DO AN EVALUATION, FAC NEEDS TO HAVE A PRESCRIPTION**
• Service Agreement Form (CLICK HERE)
• Physical Therapy – Patient History Form Adult (CLICK HERE)

Registration Form
Print out and complete the following form, then send it by fax or bring to the clinic.
• Patient Registration Form (CLICK HERE)

• Hippa Notice of Privacy Practices (CLICK HERE)
• Authorization to Release Information (CLICK HERE)

PLEASE NOTE: If these forms are not filled out, please arrive 15 minutes early to your evaluation to fill out paperwork.

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