Patient Forms

Please complete and bring the following documents with you on your first appointment.

New patient intake package

  • New patient intake forms (English or Spanish)
  • State-issued photo id (e.g. driver's license)
  • Health insurance card (if insured)
  • Doctor's referral (if you have one)
  • Any medical records about your condition from other providers (e.g. X-ray, MRI, or doctor's reports)

Information about your condition

Please also complete the following questionnaire(s) as applicable depending on your condition:

Information needed for work-related injuries

  • Employer's name, address, and phone number (under-which you filed the worker comp claim)
  • Worker compensation insurance carrier's name, claim number, and adjuster name and phone number.
  • Doctor's referral (REQUIRED)
  • Worker's compensation commission (WCC) claim number.  You can obtain one in Maryland by completing this online form.

Information needed for motor vehicle-related injuries

  • Please complete this questionnaire.
  • PIP claim information from your auto insurance, or the driver's auto insurance (if you were a passenger), including the PIP carrier name, claim number, adjuster name and phone number, and any correspondence you received from the carrier.
  • Your auto insurance card and policy declaration page showing coverage limits, insured persons, and covered vehicles (this is usually the first page of the policy which you can obtain from your auto insurance agent).
  • The liability claim information from the at-fault person's auto insurance, including the liability carrier name, claim number, adjuster name and phone number, and any correspondence you received from the carrier.
  • Police report (if available)
  • The completed and signed PIP application required by your auto insurance carrier below: