Intake Form
» Intake Form :

Print and complete these forms on your time. You can either fax or email the forms and your doctor’s referral to FYZICAL of Jacksonville prior to your first visit, or you can bring them with you to your first visit.

Fax number: (904) 223-2365
Email: jaxpt@fyzical.com

All New Patients: please select, print and fill out both of the following forms:

NEW PATIENT INTAKE FORM

NEW PATIENT PAYMENT AUTHORIZATION FORM

Please select, print and fill out one of the following pain questionnaires:

(If you are being treated for difficulty with walking or balance, please fill out the leg pain questionnaire. Your therapist will then review the questionnaire and possibly do further testing during your evaluation.)

BACK PAIN QUESTIONNAIRE

NECK PAIN QUESTIONNAIRE

SHOULDER, ELBOW, ARM, WRIST AND HAND QUESTIONNAIRE

HIP, KNEE, ANKLE, QUESTIONNAIRE

United Healthcare Patients: please select, print and fill out the following form:

UNITED HEALTHCARE PATIENT SUMMARY FORM

Patients who are Minors (under 18 years old): Parent/Guardian please select, print and fill out the following form:

PARENTAL CONSENT FORM

Additional Forms, Notice of Privacy Practices, Adobe Reader Download:

MEDICATIONS LIST

PATIENT SURVEY

NOTICE OF PRIVACY PRACTICES

FREE ADOBE READER DOWNLOAD