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Not Sure if PT Can Help?

If you are not sure if or how physical therapy can help you, fill out our form to request a 15-minute phone call with a licensed physical or hand therapist to discuss your clinical issue. They can help you determine if therapy is right for you, before you request an appointment.

Name

Phone

Zip Code

Affected Body Part

What prompted you to request a screening with a MOTION therapist?

Courtesy Screening Consent Waiver

Name(Required)

Date of Birth(Required)

Medical History(Required)

Do you have or have you ever had any of the below? Select all that apply.

Current Medications(Required)

Are you currently taking any prescription or non-prescription medications?

Yes

Medication List(Required)

Please list all medications.

Health Conditions(Required)

Are there any health conditions that might limit your participation in this complimentary screen?

Yes

Condition List

Please list all health conditions that might limit your participation in this screening:

Terms and Conditions

The complimentary injury screen is a free wellness service that is designed to promote healthy pain free living (“Screen”). The licensed professional providing the Screen will not be performing a comprehensive rehabilitation therapy evaluation, but only making a determination as to whether a comprehensive rehabilitation therapy evaluation and/or referral to another health care professional is required.

The Screen is not a physical or occupational therapy treatment intervention or the provision of any other health care service that is required to be provided by an individual licensed or certified by a state licensing board, and therefore no plan of care and/or medical record will be created in conjunction with the Screen.

The Screen has no monetary value. The provider of the Screen will not bill an insurance company for the Screen. Eligibility to participate in the Screen is not conditioned upon obtaining other services from the provider of the Screen and/or using the provider of the Screen for any other service.

By my signature below, I acknowledge that I have completely read, fully understand, and agree to the terms, conditions, and content in this form; I certify that I am not a federal health care program beneficiary and that my participation in the complimentary Screen is not conditioned upon obtaining other services from the provider of the Screen and/or using the provider of the Screen for any other service; and I consent to receive a complimentary Screen.

Guardian Name

If screening participant is under 18 years old, provide Guardian Name.

Participant/Guardian Signature(Required)

By entering your name here, you are e-signing this waiver and consenting to a complimentary screening.

Send me a copy of my responses

Diabetes or Thyroid Condition
Hernia
Asthma
Foot Orthotics
Knee Injury
Shoulder Injury
Neck Injury
Difficulty with Physical Exercise
Chronic illness and/or condition
History of lung or breathing problems
Bone, ligament, or tendon problems
Heart problem/Chest pain/stroke
Epilepsy or Seizure
Osgood-Schlatter Syndrome
Ankle/Foot Injury
Back Injury
Elbow/Hand Injury
Increased/High Blood Pressure
Advice from a physician not to exercise
Recent Surgery (last 12 months)
Pregnancy (now or within last 3 months)
Muscle or Joint Problem
None of the above

Not Sure if PT Can Help?

Courtesy Screening Consent Waiver

Terms and Conditions

Get Started with MOTION

Ready to Start Physical Therapy?

Not Sure if PT Can Help?