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In pain, same day appointments available, Call Us! 585-484-9920

New Patient Form - Welcome to Integrated!

New Patient Form

Patient Information


Carrier

Preferred Contact Method:
Text Cell Email
Call Home Call Cell

Physicians


Emergency Contact


Fill out if patient is a minor (under 18)



Authorization for Care of Minors


Primary Insurance


Secondary Insurance


If your injury is from a car accident or work incident and you have No Fault Insurance or Workers Compensation, additional paperwork will be required. Please provide this information when making your appointment.


Financial Agreement


Authorization for Medical Records


HIPAA Acknowledgement

As required by the HIPAA (Health Insurance Portability and Accountability Act), we adhere to the standards set forth in the NOTICE OF PRIVACY PRACTICES available on our website and our front desk. This document states that we reserve the right to contact you by mail, email, or phone. We may leave messages regarding appointments, payments, and treatment issues.


Integrated Physical Therapy Offers Direct Access

The Direct Access law, Chapter 298 of the Laws of 2006, allows physical therapists with three years of practical experience to treat patients for 30 days or 10 visits without a referral or prescription from a physician. It also requires physical therapists treating without a referral/prescription to provide certain information to the patient about the possibility that treatment without a referral/prescription may not be an expense covered by the patient's healthcare plan or insurer. Medicare, Workers Comp and No Fault insurances still require a physician referral/prescription.


Cancellation and No Show Policy

We are committed to providing you, our valued patients, with excellent quality and convenient services. We reserve time in our schedule specifically for you. We ask your cooperation by making every effort to keep your scheduled appointments.

We understand that occasionally situations arise such as sickness, transportation problems, inclement weather, work, or family emergencies that make it impossible to keep your scheduled appointment. In consideration for other patients and our staff, please call as soon as possible to reschedule your appointment.

If we notice a repeating pattern of you calling to cancel your appointment on the day of the appointment, we reserve the right to apply a $20 fee for Broken appointments. We will send a bill in the mail to you.

If you do not call to cancel or reschedule your appointment, we reserve the right to charge a $20 fee for No-Show appointments. We will send a bill in the mail to you.

Please do not cancel if you are feeling worse and believe the treatment is not working. Keep your appointment and discuss any changes with your provider. Please understand that your pain will probably fluctuate as your course of treatment progresses.

Please do not cancel if you are feeling better. Keep your appointment in order to take your care to the next level of strength and to prepare for discharge.


Confidential Health Questionnaire


Medical Conditions

Please select all that apply from each of the groups below.

Muscle/Joint
Pain/Numbness
Ears/Nose/Throat
Cardiovascular
Sleep Pattern
Regular Use Of The Following
General Health
Respiratory
Urological
Women Only
Foot Support
Diagnosed Conditions

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Contact Us

585-484-9920 OR