Patient Forms


The following forms should be completed prior to your visit with Amelia Physical Therapy.


Direct Access Visit


Virginia is a direct access state, which means you can see a physical therapist, without a referral from a physician. Use these forms if you're seeing a physical therapist, without a doctor referral.

Patient Registration Form: Word | Interactive PDF
Medical History and Pain Assessment: Word
Release to Treat Form: Word 
                        
If the patient is a minor (under 18 years of age), please complete this form instead of the patient registration form.
Patient Registration Form for a Minor: Word | Interactive PDF
            
E-mail completed forms to Paula@ameliapt.com
Note: You complete interactive pdfs by tabbing through the form and completing the information online. Completed forms should be e-mailed to Paula@ameliapt.com.
            
Before Your Visit
Information to prepare you for your visit with a physical therapist.



Visit with a Doctor Referral


Please complete this set of forms, if you're seeing a physical therapist, under a doctor's direction/referral.

Patient Registration Form: Word | Interactive PDF
Medical History and Pain Assessment: Word
Release to Treat Form: Word
Direct Access Form: Word
State mandated form that is required to be completed when seeing a physical therapist without a physicians referral. Learn more (.pdf)

If the patient is a minor (under 18 years of age), please complete this form instead of the patient registration form.
Patient Registration Form for a Minor: Word | Interactive PDF

E-mail completed forms to Paula@ameliapt.com
Note: You complete interactive pdfs by tabbing through the form and completing the information online. Completed forms should be e-mailed to Paula@ameliapt.com.

Before Your Visit
Information to prepare you for your visit with a physical therapist.
            
If you have questions about going to a physicial therapist without a referral (direct access), please e-mail us at Benson@ameliapt.com.


Questions?


If you have any questions about these forms, please contact us at Paula@ameliapt.com.

Amelia Physical Therapy