(585) 425-1018
790 Ayrault Rd Fairport, NY 14450
Patient Information

Patient Forms

Before your inital evaluation, we ask you to arrive 15 minute prior to your scheduled appointment to fill out some paperwork.

If you would like to save yourself some time, please download the forms here and bring them in, along with your insurance card and perscription from your doctor.

This form must be filled out by all patients at their initial evaluation.

This form must be filled out by all patients at their initial evaluation.

This form must be filled out for all services that are being billed under NYS No Fault Insurance.

This form must be filled out for all services that are being billed under NYS Worker's Compensation Insurance

If you are planning to receive Physical Therapy without a physician referral, this is known as Direct Access to Physical Therapy services and is permissable under NYS Law for 30 days or 10 sessions of therapy, whichever comes first.  After that, a physician referral is required.  If you choose DIrect Access, then this form must be completed at you initial evaluation.

This notice is for you information.  It describes how medical information about you may be used and disclosed and how you can get access to this information.  We have copies of this available in our office.

  • IS YOUR THERAPY BEING DELAYED BECAUSE OF WORKER"S COMENSATION?  IF SO, WE STRONGLY ENCOURAGE YOU TO CLICK THE LINK BELOW AND DOWNLOAD THIS LETTER.  LET THE WORKER"S COMPENSATION BOARD KNOW ABOUT YOUR SITUATION.

FORM LETTER TO WC BOARD

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