Today's Date

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address *

City *

State *

Postal code *

Emergency Contact Name

Emergency Phone Number

I agree to receive text messages from Performance Edge Physical Therapy about my appointments.

How did you hear about our practice? *

What is the primary issue or problem we can help you with? *

Is there a secondary issue or problem we can help you with?

What are you unable to do or currently having a hard time with as a result of the problem? *

When did the symptoms begin (month/year)? *

What other types of treatment have you had for this problem? *

What Is Your #1 Goal?

Please Check Any/All That Apply to You

I've had spinal fusion surgery

I have been in a car accident/traumatic event in the last 6 months

I am currently taking blood thinners

I have a blood clotting disorder

I have had a stroke in the last 6 months

I have frequent dizzy spells

I have a metal allergy

I bruise easily

List past medical history and date of occurrence(s). Include surgeries, accidents, and other trauma(s).

List all medications you are currently taking and what the medication is used for:

Is there a chance you may be pregnant at this time? *

Please list the activities that you would like to be able to do as a result of physical therapy: (i.e. sleep, running, lifting weights, etc...) *

What type of music or which artists do you enjoy most? We play background music during sessions and want to make it something you’ll enjoy

Informed Consent

I understand that by participating in physical therapy and wellness services at Performance Edge Physical Therapy, I may engage in activities that include manual therapy, dry needling, therapeutic exercise, mobility work, strength training, and other interventions designed to improve my function and well-being.

I acknowledge that:

The nature and purpose of treatment have been explained to me, and I have the opportunity to ask questions.
There is no guarantee of specific results, and individual progress may vary.
Physical therapy and wellness treatments involve some level of physical activity, which may carry minimal risks, including temporary soreness or discomfort.
I have the right to discontinue treatment at any time and communicate any concerns to my provider.
I understand that Performance Edge Physical Therapy will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.
Photographs/video may be taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below I consent to the use of these photographs in a professional manner.
I do hereby agree and give my consent for Performance Edge Physical Therapy to furnish care and treatment that is considered necessary and proper in the diagnosing or treating of my physical condition.
I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

Signature *

Clear

Payment Agreement

I understand that payment for services at Performance Edge Physical Therapy is due at the time of service unless other arrangements have been made. I acknowledge that wellness services are not billed through insurance and that I am responsible for the full cost of treatment. If I have agreed to a package or membership plan, I understand that payments are non-refundable. I agree to the cancellation policy, which may include fees for late cancellations or missed appointments. By signing below, I accept full financial responsibility for all services received.

Signature *

Clear

Insurance Information (Optional)

If you plan to use insurance for reimbursement purposes, please submit a copy of your insurance card (front and back) below.

UPLOAD HERE:

*This will help us verify your insurance coverage and process any potential reimbursements efficiently. If you are paying out-of-pocket, this step can be skipped.

What to Wear to Your Appointment

For your appointment at Performance Edge Physical Therapy, please wear comfortable, athletic clothing that allows for easy movement.

Shorts are recommended if we will be evaluating or treating your legs
Tank top or loose-fitting shirt is best for upper body assessments.
Supportive sneakers are preferred over sandals or dress shoes.
If you have any questions, feel free to reach out before your visit!

Thank you for completing your intake form! We look forward to seeing you at your appointment!