Scheduling — Spring Back Physical Therapy

Intake Form:

Please fill out the intake form below, based on your current injury, pain, or concern. We will contact you in 1-2 business days to schedule an evaluation or consultation.

If you select “Rehabilitation” on your intake form, please see the “Physical Therapy Prescription” section below for more details.

Name

First Name

Last Name

Phone Number

Please select service(s) of interest:

Prehabilitation

Rehabilitation

Maintenance

How current is your injury?

Where are you having pain?

Briefly list and describe all areas involved. If you are not currently having pain, describe current concern/reason for service request.

How did your injury occur?

Rate your pain with ACTIVITY:

Rate your pain when at REST:

Have you had surgery?

Yes

If you answered 'Yes' above; please list what surgery you had, the date you had it, and any complications associated.

Medical History

Please list and/or describe any medical history, including but not limited to, injuries, hospitalizations, allergies, daily medications, ect.

Physical Therapy Prescription:

If you request rehabilitation services, please email a copy/picture of your official prescription to mbdpt@springbacktherapy.com prior to your evaluation. If you do not have a prescription, please call your medical provider to request a physical therapy script.

For questions, comments, or concerns regarding the intake form and/or prescription request above:

Contact

Name

First Name

Last Name

Subject

Message