atient Forms

The following 3 forms are required for your visit:
Patient Intake, Patient History and Consent for Treatment

Please fill them out by completing one of the following options:

Fill out the 3 forms, print them, and bring them to your next visit. Your information will not be saved or transmitted over the web.
--OR--
Download, print and fill out the PDF forms, then bring them to your next visit.

Foothills Physical Therapy
Boise 208.343.4700
Meridian 208.884.4647
us@foothillspt.com

Patient Intake (Form 1 of 3)

Personal Information
Appointment Date:
Therapist:
Patient Name: (Last, First, Middle)
Nickname or Preferred Name:
Home Address:
City:
State:
Zip:
Home Phone:	() - -
Work Phone:	() - -
Cell Phone:	() - -
Date of Birth:	// (mm/dd/yyyy)
Social Security Number:	- -
Gender:	Male Female
Marital Status:
Employment Information
Employer:
Employer Address:
City:
State:
Zip:
Occupation:
Emergency Contact
Contact Name: (Last, First, Middle)
Contact Phone:	() - -
Responsible Person Information (Person to be billed)
Name: (Last, First, Middle)
Address:
City:
State:
Zip:
Phone:	() - -
Work Phone:	() - -
Cell Phone:	() - -
Social Security Number:	- -
Gender:	Male Female
Date of Birth:	// (mm/dd/yyyy)
Occupation:
Employer:
Relationship to Patient:	Self Spouse Parent Other:
Note: Your information will not be saved.

Download the forms.
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Print the forms.
Complete the forms.
Fill out the forms with your personal information and sign where required. Bring in during your next visit.