Who may I thank for your referral?

How do these problems interfere with your life? What would you like to be able to do better or with less pain? What makes the problem worse?

What are your physical demands, workout, fitness goals, etc.?

Please list all medications, herbs, and supplements:

To serve you most effectively, I may request your permission to speak to other healthcare practitioners involved in your care. I usually do this via telephone or occasionally e-mail. Check the box to indicate I have your permission.

BritPT will produce bills as requested, but does not file claims with any insurance companies, including Medicare. Check the box to indicate you understand.

Check the box to indicate you have been provided with a copy of the HIPPA Practice Act to read.

The APTA require that each patient give permission for a physical therapist to treat before they do so. We perform a variety of manual therapy solutions including dry needling and prescription exercise for your specific complaint. TYPE YOUR NAME below to indicate I have your formal permission to treat you.

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