Newburgh
Pine Bush
Washingtonville
New Paltz
845.565.5054
845.744.3669
845.496.1616
845.256.0820
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New Patient Forms

Medical HistoryTo help save time at your visit to  Peak Physical Therapy, P.C.we suggest that you print out the applicable forms from the list below and bring the completed form with you.

You need Acrobat Reader to open these forms. Click here for a free download.


Please fill out the following forms for ALL patients:

Appointment Policy & HIPPA

Medical History


Please fill out the following according to the body part/parts being treated:

Quick Dash (Upper Extremity)

Lower Extremity

Back

Neck

If you have The Empire Plan or Oxford insurance plese fill out the following according to the body part/parts being treated:

Quick Dash (Upper Extremity)

Lower Extremity

Back

Neck


If your injury was a result of a car accident please fill out the the following additional form:

New York Motor Vehicle No-Fault Insurance Law Assignment of Benefits


If your therapy is covered under Medicare please fill out the following form as well.

Medicare Confidence