Back to Action Physical Therapy


Vermont Physical Therapists, Back to Action PT

Patient Forms

Reading and completing the following forms will help us to better assess your condition and ensure you receive the best treatment possible.

Please Read:
1. Welcome Letter & Insurance Information
2. HIPAA Regulations
3. Back To Action Billing Brochure

Please COMPLETE and BRING to your appointment:
1. Patient Information Form
2. Patient Authorization Form
2a. Medicare Information Form (for patients with Medicare insurance)
3. Patient Intake Form

Along with the above paperwork, you will also need to bring your insurance card to your first appointment so that we may make a copy for our records.

Please remember to wear or bring loose fitting, comfortable clothing, keeping in mind which part of your body we will be treating.

To open the files, click on the name of the form, then print it and complete it using a blue or black pen. All files are in PDF format. You will need Adobe Acrobat to read these files. Often it is already installed on your computer. If not, to download the free Adobe PDF File Reader, visit: http://get.adobe.com/reader/