Intake Form
Intake Form

Print and complete these forms on your time. You can either fax or email the forms and your doctor’s referral to FYZICAL of Jacksonville prior to your first visit, or you can bring them with you to your first visit.

Fax number: (904) 223-2365
Email: jaxpt@fyzical.com

All New Patients: please select, print and fill out both of the following forms:

NEW PATIENT INTAKE FORM

NEW PATIENT PAYMENT AUTHORIZATION FORM

Please select, print and fill out one of the following pain questionnaires:

(If you are being treated for difficulty with walking or balance, please fill out the leg pain questionnaire. Your therapist will then review the questionnaire and possibly do further testing during your evaluation.)

BACK PAIN QUESTIONNAIRE

NECK PAIN QUESTIONNAIRE

SHOULDER, ELBOW, ARM, WRIST AND HAND QUESTIONNAIRE

HIP, KNEE, ANKLE, QUESTIONNAIRE

United Healthcare Patients: please select, print and fill out the following form:

UNITED HEALTHCARE PATIENT SUMMARY FORM

Patients who are Minors (under 18 years old): Parent/Guardian please select, print and fill out the following form:

PARENTAL CONSENT FORM

Additional Forms, Notice of Privacy Practices, Adobe Reader Download:

MEDICATIONS LIST

PATIENT SURVEY

NOTICE OF PRIVACY PRACTICES

FREE ADOBE READER DOWNLOAD

Sign up for newsletter
Please wait...
Thank you for signing up.
You have been added to our newsletter list.
Yes, I would like to receive newsletters from FYZICAL Jacksonville.

Leader in the health and wellness space, providing private practices with business systems, operational support, clinical education, and proprietary technology and protocols. FYZICAL® is actively changing the healthcare landscape by providing patients with wellness programs and clinical care in: Fall Prevention, Orthopedic and Vestibular Rehabilitation

Corporate Home