Physical Therapy Intake Form
Please complete this initial intake for new patients prior to your visit. We will not be able to start your visit unless this form is completed.

At Home Therapy of Crystal Coast, LLC
Email address *
* By selecting "I AGREE" below, you confirm the email address you entered above is yours and no other individual has access to your email account. This email address should match the email address where you received the link for this intake. * *
Welcome to At Home Therapy!
Full Name *
Injury description (brief summary) *
Red Flag Questions *
How has this injury impacted your daily activities? *
Please list all medications that you are currently taking. *
Please click to download and read our "consent to treat" policy and click an answer below if you agree or disagree to the policy as written here *
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