Geril Therapy
Call Us at (866) 747-6235

New Patient Paper Work


Please print out each of these links. Fill out the information as completely as you can and bring it with you on your first appointment. This will save you 15-30 minutes of time. Below you will find a description of each of these forms to answer any questions you may have.

New Patient Paper Work

Medicare Secondary Form-(Medicare only-Required)


 

Body Part Specific Questionaires - Please print and fill out specific to the instructions given to you by our Office.

DASH

Neck Index

Back Index

Lower Extremity Functional Scale (LEFS)

BioMotion Paper work

Pain Drawing

Employer Job Description


The above links are all of the necessary paper work for your admission to Geril Therapy-Physical Therapy/Health and Wellness.

  • The HIPPA PRIVACY PRACTICES- This form is yours to keep, notifying you of our practices to keep your information private.
  • Past Medical History Form- Please fill out the entire, form and check the appropriate box, even if it is a No. Finally sign and date.
  • Release of Medical Records- This will allow us to communicate, send, and receive information with you referring physician and any other physician that you deem appropriate.
  • Consent to Treat- This form allows us to treat you as well as documents your acknowledgement of our Privacy Practices.
  • Patient information sheet- Please fill out this form as completely as you can.
  • Medicare Secondary Form- This form is mandatory by Medicare to determine if Medicare will be your primary insurance. Please fill out completely.

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Hours of Operation:
Monday–Friday,
9 a.m.–5 p.m.
Extended hours by Appointment