West Clinic: (928) 556-9935

East Clinic: (928) 214-7430

New Patient Forms

Please read, print and complete the following forms, and bring them with you to your initial visit.  We look forward to seeing you!

New Patient Intake Forms

Notice of Privacy Practices (keep for your own records)

Patient Payment Policy

We utilize evidence-based questionnaires to establish a measure of your functional baseline before treatment, to help determine progress and to defend your treatment to your insurance company.  Please select and complete one of the following questionnaires that is most appropriate for the condition for which you will be treated at our clinic.

  • For incontinence, pelvic pain, and/or pelvic organ prolapse, click here
  • For low back pain and pain radiating into the leg from the nerves in the low back, click here
  • For neck pain and pain radiating into the arm from the nerves in the neck, click here
  • For leg injuries and pain, click here
  • For shoulder injuries and pain, click here
  • For dizziness and/or vertigo, click here

Return to Top of Page