Please fill out all pages of the Medicare Intake Forms


ALSO, please select one of the following forms that best represents why you are coming for treatment.

 

                Neck Pain Form

 

                Back Pain Form

 

                Upper Extremity Pain Form  (shoulder, elbow, wrist, hand)

 

                Lower Extremity Pain Form   (hip, knee, ankle, foot)

 

                Balance Form 

A physician referral is not required to start physical therapy.

Please bring your forms, along with your ID, insurance cards, and physician referral to your initial appointment.

               

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Same day appointments are available!

Fill out an easy appointment request here using your phone or tablet.

1024 Centre Ave., Suite 100
Fort Collins, CO 80526

Phone: (970) 224-4141

Fax: (970) 797-1227

© 2020 by ProActive Physical Therapy and Performance Center, Fort Collins, Colorado  80526