Your First Visit With Us

Welcome to the Back to Health Family! We are committed to providing you with a professional and individualized physical therapy experience tailored specifically for you.
Please see below some guidelines on how you can make your appointment with us as smooth as possible:

What To Bring

✓ Your Insurance Card

✓ Your Physical Therapy Prescription/ Referral Form (from your doctor)

✓ Your Co-Payment/Deductible Payment (we accept Cash, All Major Credit/Debit Cards, Checks & Apple Pay)

✓ A copy of any Radiology Scans, X-Rays or CAT-Scans

Сlothing To Wear

Wear comfortable clothing that will:

✓ Allow the Physical Therapist access to the injured body part

✓ Loose/Comfortable enough for exercise movements

✓ If you coming from work don’t worry we have disposable shorts and gowns to change into

✓ Wear appropriate footwear for exercise

Arrival Time

✓ Arrive 30 minute prior to your appointment time to fill out the necessary paperwork

✓ If you would like to fill out the form ahead of time, click on the New Patient Form below to expedite your check-in process

New Patient Form To Fill

PATIENT INFORMATION






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REFERRAL INFORMATION

In order to help us give proper gratitude to our referral sources, would you please tell us how you first heard about Back To Health Physical & Occupational Therapy?

DoctorFriend/FamilyOur Website
Insurance CompanySearch EngineFacebook
YelpGoogle+

IN CASE OF EMERGENCY





INSURANCE INFORMATION










INSURANCE INFORMATION












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MEDICAL HISTORY

Has a doctor or health professional ever told you ? Please check all that apply:

Congenital Heart DefectHeart ProblemsAnginaHeart DiseaseTendon or Muscular PainPalpationPacemakerHigh or Low Blood PressureChest PainAbdominal PainCoughingWheezing or ExertionBloatingGoutRheumatoid ArthritisGasAnemiaUlcersShortness of BreathThyroid Problems
BronchitisKidney DiseaseTuberculosisAsthmaChronic Cough a StrokeLatex AllergyPneumoniaHepatitis A, B, CCancerSkin ProblemsDepressionJoint Replacement / RepairGastrointestinal IssuesPsychologicalHigh or Low Blood SugarHigh CholesterolEmphysemaPoor Balance / Recent FallsLiver DiseaseDizziness
Prostate ProblemsLung DiseaseVertigoEpilepsyAllergiesFaintingSeizure DisordersDiabetesBlackoutsCirculation ProblemsAlcoholismSevere HeadachesBlood ClotsLyme DiseasePainful BowelsLoose StoolConstipationHIVOTHER

Please provide details regarding the above checked conditions:

SURGICAL HISTORY

List any surgical procedures you have had and the dates they were performed:

PREVIOUS INJURIES / ACCIDENTS

List any previous injuries you have sustained and the approximate dates of injury:

MEDICATIONS

Please list ALL over the counter and prescription medications you are currently taking:
Example: Pain Killers, Anti-Inflammatory, Muscle Relaxers, Anti-Depressants, Blood Pressure, Antibiotics,
Vitamins / Herbal Supplements, etc.

DIAGNOSTIC TESTING

Please check any diagnostic testing or treatments you have completed for this condition:

MRINerve Block
CT ScanInjections
X Ray
Bone Scan
EMG

If you have any reports from these tests, please submit a copy to your therapist for review.

DIAGNOSTIC TESTING

Excellent
Good
Fair
Poor

Low
Moderate
High

Low
Moderate
High

Low
Moderate
High

Excellent
Good
Fair
Poor

Excellent
Good
Fair
Poor






Insurances We Accept
  • 1199
  • AETNA HMO
  • AETNA ALL PLANS
  • AFFINITY / ESSENTIAL
  • AGE WELL FIDA
  • AIG
  • AMERICHOICE by UNITED HEALTHCARE
  • AMERIGROUP
  • ATLANTIS
  • CENTERLIGHT MLTC
  • CENTERS PLAN FOR HEALTHY LEAVING
  • CIGNA HMO / PPO / POS
  • EASYCHOICE GROUP
  • ELDERPLAN
  • EMPIRE BC / BS HMO
  • EMPIRE BC / BS PPO / POS / EPO
  • FIDELIS
  • GHI MEDICARE
  • GUILDNET MLTC / FIDA
  • HHH CHOICE
  • HEALTH FIRST Medicaid / Medicare
  • HEALTH PLUS
  • HIP
  • MAGNACARE
  • MEDICAID
  • MEDICARE
  • METROPLUS
  • MULTIPLAN
  • NEIGHBORHOOD
  • NO FAULT
  • NY MED
  • ORTHONET / CIGNA / AETNA
  • OXFORD
  • PHCS
  • SELECT PRO
  • SENIOR WHOLE HEALTH FIDA
  • UHC THE EMPIREPLAN / OPTUN
  • UNITED HEALTHCARE (All plans)
  • US FAMILY HEALTH PLAN
  • VNS
  • WORKMEN’S COMPENSATION
  • PHCS
  • SELECT PRO
  • SENIOR WHOLE HEALTH FIDA
  • UHC THE EMPIREPLAN / OPTUN
  • UNITED HEALTHCARE (All plans)
  • US FAMILY HEALTH PLAN
  • VNS
  • WORKMEN’S COMPENSATION

If you don’t have insurance – no problem!

We also accept Cash, Debit, Checks.