For your convenience, we are providing our office forms to you before your first appointment. You may download these forms and fill them in on your computer, or print them and fill them in manually.
Please complete all
Please choose one
The column on the left includes three forms that must be filled for your first visit. The column on the right includes questionnaires specific to areas of the body. Please choose one that best describes your injury.
On a PC: Download the file (Right click, Save Target As...) and open with Adobe Reader. Click on each blank to type in your information, and click in each box to place a check mark. When you are finished, you may save and print the file. If you do not have Adobe Reader installed on your computer, you may download it here:
On a Mac:Download the file (Control+click, Save linked file as...) and open with Preview. Click on each blank to type in your information, and click in each box to place a check mark. When you are finished, you may save and print the file.
Eclipse Orthopedic Rehabilitation accepts and files claims for most insurance companies and is an approved Medicare Part B provider. While we place courtesy calls to the insurance company to investigate the benefits of your plan, it is ultimately your responsibility to verify your physical therapy benefits. Applicable deductible amounts and/or co-payments are the patient’s responsibility, however, we make every effort to accommodate each patient’s financial needs.