Results Physiotherapy | Patient Forms

All Patients

Click below to download the Results Physiotherapy Patient Form PDF which includes Patient Medical History, Payment for Services Rendered, Privacy and Assignment of Benefits, and Appointment Policy.

Results Physiotherapy Patient Forms (PDF)

HIPAA Notice of Privacy Practices (March 2015)

Specialty Services Patients:

These additional forms are for Male and Female patients that are being treated for Specialty Services at Results Physiotherapy, including Pelvic Health, Incontinence, Women’s Health and Sexual Dysfunction.
*Please note that these are comprehensive medical history forms that include questions that cover several different pelvic health conditions that a patient may be seeking therapy for. Patients only need to answer questions associated with the problems they are experiencing or being referred to therapy for.

Female Specialty Services History and Intake Form (PDF)

Male Specialty Services History and Intake Form (PDF)

Consent for Pelvic Floor Muscle Evaluation (PDF)

 
Dry Needling Icon

Request an Appointment

Schedule

We use cookies to ensure that we give you the best experience on our website. If you continue to use this site, we will assume that you are happy with these terms.