Patient Forms

As a time-saving feature, ept Rehabilitation has provided many of our forms in downloadable format (Adobe’s pdf and Word document format). You may download a free copy of Adobe Acrobat Reader.

As you call to schedule your appointment, our office staff can tell you which forms you’ll need and why they are required. Completing the forms prior to coming to us will make your initial encounter with us a more pleasant experience.

These are the general information forms that you will need to complete and sign before being treated.

PDF: Patient Information Form

Patient Forms: #1 – Patient Intake Form#2 – Patient Consent to Treat#3 – Insurance Benefits Patient Form#4 – Appt. No Show Agreement#5 – Patient Release for Family Member#6 – NOTICE OF PRIVACY PRACTICES#7 – List of Medications Form#8 – Pain Questionnaire Form

Español:Spanish NOTICE OF PRIVACY PRACTICES

*For Pelvic Floor Patients – Pelvic Floor Information Forms: 25 Keeping A Record Of Bladder Function26 Daily Voiding Log-Blank03 Health History-Symptom Questionnaire