AirOn Physical Therapy — New Patient Intake

Tell us about you

A few basics first — then we tailor the rest to your situation. About 5 minutes.

Are you a new or existing patient? *

New patient Existing patient

Full legal name *

Date of birth *

Phone *

Email *

Home address FOLLOW-UP IF BLANK

What brings you to therapy today? *

A work injuryWorkers’ Compensation A car accidentAuto / PIP / No-fault Using my health insurancePrivate insurance Paying for myselfCash / self-pay

Company

Welcome back

We just need the reason for your visit — the front desk will handle the rest and contact you to schedule.

Reason for this visit *

Preferred appointment times *

Your case details

Based on how your care is paid for. Fields marked with a tag are chased by our front desk if left blank — they protect your claim.

Health & symptom history

This helps your therapist prepare for your evaluation.

Describe your symptoms *

Pain level right now * — 5/10

No painWorst imaginable

When did the symptoms begin?

Dominant side

Right Left

Prior treatment or surgeries (anything relevant)

Any imaging (X-ray, MRI, CT) for this?

Yes No

Current medications

Quick safety screen — do you currently have any of these?

Numbness or weakness in arms/legs

New bowel or bladder problems

Unexplained weight loss

Severe night pain that wakes you

What are your goals for therapy?

How should we contact you?

Your privacy choices — we follow these exactly.

Preferred contact method *

Call Text Email

Best time to reach you

May we leave a voicemail or text that mentions your care? *

Yes No — ask me to call back only

Consent & signature

Review each section and check the box to agree. One signature at the end covers the packet.

Signing as

Patient Parent / Guardian Authorized rep

Type your full legal name to sign *

This electronic signature has the same legal effect as a handwritten signature.

↻ Start a new intake