All necessary documents can be completed during your first appointment. If you would like to fill them out ahead of time, feel free to print and complete the form below or call us 252-565-8812 and we will be glad to mail you a copy.

For your first appointment, bring the following:

  • Completed Patient Intake Forms 
    • Aetna/United Healthcare/Optum patients are required to complete the following forms for insurance purposes: 
      • Patient Summary Form and STarT Back Screening Tool as well as one of the following (complete the most pertinent form): 
        • Upper Extremity Functional Index
        • Lower Extremity Functional Scale 
        • Neck Index 
        • Back Index 
    • Medicare patients are required to complete one of the following forms for insurance purposes (complete the most pertinent form): 
      • Upper Extremity Functional Index 
      • Lower Extremity Functional Scale 
      • Neck Index 
      • Back Index 
  • Insurance card
  • Photo ID 
  • List of medications
  • Referral from physician (if applicable)
  • Imaging Report (if applicable)
  • Comfortable, athletic clothing

Patient Intake Forms

Download (PDF, 964KB)

Patient Summary Form and STarT Back Screening Tool

Download (PDF, 366KB)

Upper Extremity Functional Index 

Download (PDF, 86KB)

Lower Extremity Functional Scale 

Download (PDF, 109KB)

Neck Index

Download (PDF, 124KB)