Please arrive to your first appointment 20 minutes
early for check in and insurance verification
Medical History
Form This form should be completed by all patients, new and
returning, for your first therapy appointment. Please print, fill out, and bring
with you to your first therapy appointment.
HIPAA
Form This
form describes how health insurance information about you, as a patient of this
practice, may be used and disclosed. This is required by the Privacy
Regulations. Please print, sign, and bring with you to your first therapy
appointment.
Authorization for
Treatment This form should be completed by all
patients, parents, or legal guardians of minor patients. Please print, initial,
sign and bring with you to your first therapy appointment.
Cancel / No Show
Policy This form explains our
policy on canceling or no showing for appointments. Please read prior to your
first appointment.
Consent for
Minors This
form needs to be completed by a parent or legal guardian if you are
unable to accompany your minor for their first therapy visit. Please print,
sign, and send with your minor to their first therapy appointment.
Medical Records Release
Form If you are requesting a copy of your medical records, please
complete this form and fax or mail as instructed on form. For specific
questions, call (651) 747-4339 or (651) 747-4341.
WOMEN'S HEALTH
PATIENTS
Women's Health Medical History
Form This form should be completed by all Women's Health
patients, new and returning, for your first therapy appointment. Please
print, fill out, and bring with you to your first therapy
appointment.
Bladder and Bowel Symptom
Questionaire This form should be completed by all Women's
Health patients, new and returning, for your first therapy appointment.
Please print, fill out, and bring with you to your first therapy
appointment.
TMJ
PATIENTS
TMJ Questionnaire This form is to
be completed by TMJ patients, new and returning, for your first therapy
appointment. Please print, fill out, and bring with you to your first
therapy appointment.
Physician
Forms Referral Pad This
form is available for physicians to download if they run out of referral pads.
If you are a physician and need more referral pads, please contact Kathleen
Picard at 651-351-9264 or kpicard@therapypartners.com