Online Patient Registration Form

Medical information profile

  • Patient Information

  • Please enter you date of birth MM-DD-YYYY
  • I hereby agree and give my consent to medical treatment in treating my physical condition. I authorize release of any medical information needed to process my claim. I understand that I am responsible for any charges that are not covered by my insurance carrier. Furthermore, I understand that I am responsible to inform the office of any changes that occur. I authorize release of payment directly to Timberlane Physical Therapy regardless of participation in or out-of-network. Should I default on my financial responsibility and collection action is necessary, I will be responsible for collection costs that are incurred.

  • Please read the disclosure and sign
  • MM slash DD slash YYYY
  • Primary Insurance

  • Answer if Policy Holder is different from Patient

  • Please enter you date of birth MM-DD-YYYY
  • If Auto or Worker’s Comp

  • Secondary Insurance

  • Answer if Policy Holder is different from Patient

  • Cancelled Appointments

  • At Timberlane Physical Therapy we believe it is important for our patients to keep all of their scheduled appointments, in order to be successful in reaching their treatment goals. With that in mind, we have developed the following cancellation policy.

    It is our policy that any appointment that needs to be cancelled must be cancelled with 24 hours’ notice. If appropriate notice is not given there will be a charge of $25 for a broken appointment. Broken appointment charges are not billable to medical insurance plans and will be the patient’s responsibility.

    Please remember that our objective is to help you meet your physical therapy and functional goals. It is essential to keep your scheduled appointments for a positive outcome.

    By my signature below, I acknowledge that I have read and will abide by this Cancellation Policy.

  • Please read and sign disclosure
  • MM slash DD slash YYYY
  • Designated Individuals Authorization Form

  • I hereby authorize on or all of the designated parties below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information.

    Authorized Designees

  • Notice of Privacy Policy

  • Uses and Disclosures of Health Information

    Timberlane Physical Therapy is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein. Timberlane Physical Therapy uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. Timberlane Physical Therapy may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law in any other situation. Timberlane Physical Therapy’s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Timberlane Physical Therapy may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time.

    Patient’s Individual Rights

    You have the right to review or obtain a copy of your personal health information at any time. If you request photocopies of your personal health information, we may charge you $0.25 per page for these copies. You have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may request in writing that we do not disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Timberlane Physical Therapy will consider all such requests on a case by case basis, but the practice is not legally required to accept them.

    Concerns and Complaints

    If you are concerned that Timberlane Physical Therapy may have violated your privacy policy rights or if you disagree with any decision we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed. You may also send a written complaint to the U.S. Department of Health and Human Services. For further information on Timberlane Physical Therapy’s health information practices or if you have a complaint, please contact the following:

    Timberlane Physical Therapy Office Administrator 321 Main St • Suite D • Winooski, VT 05404

    I acknowledge that I have seen the “Notice of Privacy Practices”. I understand that I may ask questions about the “Notice of Privacy Practices” at any time.

  • Please read and sign disclosure
  • MM slash DD slash YYYY
  • Medical Screening Questionnaire

  • MM slash DD slash YYYY
  • Enter Feet - Inches
  • Weight in pounds
  • During the past month have you been

  • Please list all medications you are currently taking:

  • (amount in mg, ml, etc.)
  • (how often)
  • (oral, injection, patch, etc.)
  • Using the 0 to 10 scale, with 0 being “no pain” and 10 being the “worst pain imaginable” please describe

  • Body Chart

    Please download and print the attached body chart PDF, then fill it out and bring the form with you to your appointment.

    Click to Download Body Form PDF

  • This field is for validation purposes and should be left unchanged.