Patient Forms

Personal information, emergency contact, primary care physician, and preferred location. Required before any treatment can begin.

Current and past medical conditions, prior surgeries, current medications, allergies, and relevant family history. Reviewed by your therapist before the evaluation.

Confirms you have received and reviewed the Dynamic Physical Therapy Notice of Privacy Practices, as required by the Health Insurance Portability and Accountability Act.

Your rights as a patient, your consent to evaluation and treatment, and your acknowledgement of the financial responsibility policy.

Authorises Dynamic Physical Therapy to bill your No-Fault insurance carrier directly on your behalf and to receive payment for covered services. Must be signed before No-Fault billing can begin.

Date, location, and circumstances of the accident; vehicles involved; reporting information; and the identity of your No-Fault insurance carrier and claim number.

Authorises Dynamic Physical Therapy to release your medical records and clinical reports to your No-Fault insurance carrier and, if applicable, your personal injury attorney.

Authorises Dynamic Physical Therapy to bill your Workers' Compensation carrier directly. Your WC case number, employer name, and carrier information are required to complete this form.

Date and description of the work-related injury or illness, the body parts affected, how the injury occurred, and whether it has been reported to your employer and the Workers' Compensation Board.

Authorises Dynamic Physical Therapy to release your medical records and reports to your Workers' Compensation carrier and, if applicable, your WC attorney.

Use this form to authorise Dynamic Physical Therapy to release your records to another healthcare provider, specialist, or third party not covered by the specific No-Fault or WC authorisation forms above.

A validated functional outcome questionnaire completed at the start of care and at intervals during treatment. Results are used to objectively track your progress and adjust your treatment plan accordingly.

Required for patients under 18 years of age. A parent or legal guardian must sign to authorise evaluation and treatment. The guardian must be present at the initial evaluation.

Required before participating in telehealth physical therapy sessions. Confirms your understanding of the telehealth platform, technology requirements, privacy limitations, and your consent to remote care delivery.