Patient Forms

Print and fill out our New Patient Forms at home to save some time for your first appointment! If you have any questions, feel free to call or ask when you first arrive.

Patient Information & Consent Forms

Patient Self-Pay Program

Virtual Visit Consent for Treatment

New Patient Forms

New Patient Forms – Spanish

Notice of Privacy Practices

Notice of Privacy Practices – Spanish

*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.

First Name
Last Name
Phone*
Email*
Which clinic is most convenient for you?*
Primary complaint/condition*
Who is your Primary Care Physician?
(If you are unsure, please leave blank)
Who is your insurance carrier?
(If you are unsure, please leave blank)
How did you hear about Back in Motion?
Notes

Our Locations

94 Main Street #2
Gorham, ME 04038

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

185 Ocean Street
South Portland, ME 04106

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

1041 Brighton Avenue
Portland, ME 04102

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

4 Main Street Unit T2
Newport, ME 04953

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

797 Wilson Street
Brewer, ME 04412

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

The Coronavirus and our commitment to clinic safety

Learn More