Intake Forms

» Intake Forms

The following forms are provided online for your convenience. Please choose the category that applies to you, download the appropriate forms, fill them out, and bring them in with you. The forms are available as PDF files. You will need Acrobat Reader to open them.

  • Self-pay clients: use this set of forms if you will not be utilizing insurance or if you plan to submit to your private insurance for reimbursement.
  • Workers' compensation: use this set of forms if you were injured on the job.
  • Medicare: use this set of forms if you wish to utilize your Medicare benefits.

For more information about payment options, please contact the billing office at (408) 376-0900.