Before Your Visit

Patient Intake Form

Completing this form ahead of time means more hands-on treatment during your first session. It takes about five minutes.

Patient details

Full name

Date of birth

Phone

Home address (optional)

Emergency contact name

Emergency contact phone

Insurance & referral

Insurance provider (optional)

Member ID (optional)

Referring physician (optional)

Your condition

Help your therapist prepare an assessment tailored to your symptoms.

What brings you in?

When did symptoms start? (optional)

Current pain level (0–10, optional)

Medical conditions (optional)

Current medications (optional)

Allergies (optional)

Past surgeries (optional)

Required documents

Upload clear photos or PDFs (10MB max per file). Files are stored privately and visible only to clinic staff.

Photo IDRequired

Driver's license, state ID, or passport.

Insurance cardRequired

Front and back if possible (PDF or image).

Physician referral / prescriptionOptional

Required if your insurance plan needs a referral.

Imaging or surgical reportsOptional

X-ray, MRI, or operative reports related to your condition.

Consent

I consent to physical therapy evaluation and treatment at Regen Rehab Therapy.I acknowledge the clinic's privacy practices and agree to the secure handling of my health information and uploaded documents.