Forms

window1All patients need to fill out the following new patient paperwork before we can begin your first appointment. Feel free to come in early and fill them out, or to print these forms and bring them in with you after completing them at your convenience.

NEW Episode Intake Form and HIPPA Agreement

Medical History Form

Additional forms you may need to fill out if you are being seen for:

Your Back

Your Neck

Your Shoulder, Elbow or Wrist

Your Hip, Knee or Ankle

If you are covered by the Dartmouth Student Group Health Plan (DSGHP – HealthSmart) through Dartmouth College please complete the attached form and review the expected out of pocket coverage information here.

Appointments available Monday through Friday 8AM - 7PM

Barlow - Ellingson
Sports and Orthopedic
Rehabilitation
tel: 603-653-0040
fax: 603-653-0041
email: kylie@befit-pt.com
45 Lyme Road
Suite 101
Hanover, NH 03755
Copyright 2014 BE Fit Physical Therapy. All Rights Reserved.