Patient Forms

At Balance Physical Therapy, we want you to feel as comfortable as possible, both emotionally and physically. Please feel free to call our office with any questions or concerns. Our office telephone is 603-890-8844.

Our therapists will take all the time in your first appointment to work directly with you. The most important form is the Patient Medical History. Please complete this form and bring it with you. 

We ask that you review our Financial and Cancellation Policies. We are required to have you read The Health Insurance Portability and Accountability Act (HIPAA) form. Once you have read them, please sign the Patient Release Form and bring it with you. 

If you are coming to Balance Physical Therapy for Exercise Training, please read and sign the “Exercise Release” form. 

If you prefer to fill them out in our office, please arrive 10-15 minutes early. Our therapists require all the time in your first appointment to work directly with you so please do come early if you plan to do the paperwork in our office. 

What FORMS do you need to bring with you to your first visit?

1. General Patient History Form and Neck and Back History Form
2. Patient Release Form ( (Please read the HIPPA, Financial and Cancellation Policies listed below and then sign this Patient Release Form)
3. HIPPA Policy (Please Read)
4. Financial and Cancellation Policies (Please Read)
5. Exercise Release Form

What else do you need to bring to your First Visit at Balance Physical Therapy?

1. Prescription or Referral for Physical Therapy
2. Your Insurance Card (Insurance Companies that we work with)
3. If you are being treated for an Auto Accident or Job-Related Injury, please bring Your Insurance Claim #

On all your visits, please bring:

1. Your calendar or datebook so we can plan your treatment schedule.
2. Insurance co-payment (we accept cash, check, major credit cards).