Intake Forms
(4 pages)
Every new patient is required to complete the following general Intake Forms.
Every new patient is also required to complete the ONE  form that corresponds to your injury. (Don't worry about calculating the score at the end, we'll take care of the math).
Neck Injury
(1 page)
Back Injury
(1 page)
If you are using one of the following insurances, please complete the corresponding form as well.
(1 page- bottom section only)
(2 pages)
Finally, please complete the following form if you do not have a doctor's referral or prescription for physical therapy. (Don't worry: we'll call your insurance before you come in to verify that they'll pay for treatment even without a referral and let you know if there are any issues.)
Direct Access Form
(1 page- top section only)
Forms to Download
Save some time at your first appointment by printing out the necessary forms and bringing them with you already filled out. If you have any questions, we'll walk you through it when you come in.

Athalon Physical Therapy
115 East 57th Street, Suite 605 • New York, NY 10022
Tel: (212) 838 - 8023 • Fax: (212) 838 - 8027 •

115 EAST 57TH ST, SUITE 605   •   NEW YORK, NY 10022   •   (212) 838 - 8023   •