Bergen County, Montvale, NJ

"Download New Patient Forms"

On arrival for their first visit at Summit Physical Therapy & Sports Care, every patient is required to fill out all the necessary forms that he/she will need to get started. 

For your convenience, we have provided the necessary forms for you to download directly to your computer.  These are the same forms you will be expected to fill out upon arrival to the facility.  By taking the time to download them now, and filling them out, you save time.  Both ours and your own (your time is worth something too!).  Plus, you can fill them out at your own leisure, making sure to avoid unwanted mistakes.  Please take advantage by downloading them here.

You will need these forms prior to your initial evaluation.  We cannot treat you without them. These forms are in PDF format.  You will need adobe acrobat reader.  If you do not have adobe acrobat reader please go to www.adobe.com to get it.  It is available for instant download free of charge. If you should have difficulty, email us and we will send you the forms via an email attachment (forms will be in Microsoft Office Word format). 

While it is not necessary for you to download these forms ahead of time, it is advised.  Taking the time to fill them out at your own leisure prevents errors and speeds up the process of “getting started."


The download includes:

Patient Data Sheet.  Request for information about who you are, where you live, your insurance provider……etc. 

Medical Intake form.  Request for information on past medical history, and the types of medication you may be taking.

Consent to Treatment form.  This allows us to provide assessment, therapeutic procedures, and interventions that follow in accordance with the state practice act. 

Physical Therapy Attendance Policy.  Information related to your attendance (vital to your recovery), cancellations and co-pays. 

After taking the time to fill these forms out, bring them with you on your first day.  If you are unsure of something and/or need clarification, you can contact us and/or leave it blank.  More will be explained to you once you arrive.  
We thank you in advance for downloading and filling out these forms. 

Your patronage to our facility is appreciated.

Clinical Outcome Forms: We use these forms to determine your ability quantitatively. We compare the scores given during the initial evaluation, re-evaluation(s) and discharge summary. This allows us to document your progress with greater accuracy. Many insurance companies require these forms to help determine the amount of visits they will "authorize." So please answer carefully.
Download the DASH This form should be used by those individuals having problems with the arm, shoulder or hand.
Download the LEFS This form should be used be those individual having problems with the hip, knee, foot or ankle.
Download the Neck Index This form should be used by those individuals having problems or pain from their neck.
Download the Back Index This form should be used by those individuals having problems or pain from their back.

We would also like to make available to you the HIPAA Notice of Privacy Practices. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please download it and review it carefully.


Right side back pain from bulging discs

 

Just for visiting our website, please feel free to download and keep our free ebook! It is an instructional ebook with a step by step "how to" on making your own hot packs, cold packs, and paraffin bath. This is a 30 dollar value available to you for free as our gift! To download your free gift, please click here and save it to your own computer. Compliments of Summit Physical Therapy & Sports Care!

 

 

 

For an appointment please call Summit Physical Therapy & Sports Care at 201.627.0100

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