Patient Forms

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At Lifespan Physical Therapy, Occupational Therapy, & Speech and Language Pathology Services, PLLC, we want to make your visit as easy as possible. Patient Forms are provided to download, print, and complete prior to visiting for the first time.  Please bring forms with you.

 

 

 

 

New Patient Forms

 

 

Specific Injury Forms

 

The following forms are specific to type of injury or body region to be addressed. Please print the form pertinent to your need, complete, and bring with you on your first visit.  These forms are required for Medicare, Empire, MPN, No Fault, and Worker’s Compensation only.

 

Release of Information Form:

 

If you would like Lifespan Therapies to release your therapy record in part or whole to a professional of your choice, please complete the following form and return it to our office.

Personal Health Information Release Form

 

Please contact our office at 315.364.7570  for further assistance if required.  Thank you.

 

To download forms, access Adobe Acrobat here.