Patient Forms

Patient Forms

At Back in Motion Physical Therapy, we want to maximize your time with us. Prior to your first visit, please follow the steps below:

 

In-Clinic or At-Home Visit:

Click on the applicable form below, fill out and submit online.

New Evaluation Form – English / Spanish

 

Virtual Visit:

Click on the applicable forms below, fill out and submit online.

New Evaluation & Consent Forms

Medicare & Self-Pay Program

Existing Patient Virtual Visit Consent

 

Notice of Privacy Practices

Notice of Privacy Practices – English / Spanish

 

 

Virtual Visit:

Click on the Patient Form that applies to you, fill out and submit online.

First Time or Returning:

Patient Information & Consent Forms

Medicare & Self-Pay:

Patient Self-Pay Program

Currently Being Seen:

Virtual Visit Consent for Treatment

 

*Note: Based on insurance there may be additional paperwork

Get started on the journey back to being you.
From your first visit with us, you’ll find people who are dedicated to your health, well-being, and making your care as pleasant as possible.

Our Locations

Gorham

94 Main Street #2
Gorham, ME 04038

Phone: (207) 839-5860
Fax: (207) 839-2499

South Portland

185 Ocean Street
South Portland, ME 04106

Phone: (207) 799-8226
Fax: (207) 799-9340

Portland

1041 Brighton Ave
Portland, ME 04102

Phone: (207) 699-4111
Fax: (207) 773-8814

Dexter

4 Main Street Unit T2
Newport, ME 04953

Phone: (207) 924-0077
Fax: (207) 924-0078

Brewer

797 Wilson Street
Brewer, ME 04412

Phone: (207) 992-4042
Fax: (207) 992-4043

Waterville

(Coming Soon)
120 Elm Plaza

Waterville, ME 04901

Phone: (207) 707-4789
Fax: (833) 989-0156

Auburn

(Coming Soon)
600 Turner Street Ste 2

Auburn, ME 04210

Phone: (207) 707-4788
Fax: (833) 702-9005