Medical History Form
Thank you for your ongoing interest in our work. To start the scheduling process, please Complete and Submit a Medical History Form so we can get you into our system and start to build your chart.
Physician’s Referral Sheet
To help keep you safe and assist with possible insurance reimbursement, print and bring this form to your physician for them to sign.
Thank you for your ongoing interest in our work. To start the scheduling process, please Complete and Submit a Medical History Form so we can get you into our system and start to build your chart. To help keep you safe and assist with possible insurance reimbursement, print and bring this form to your physician for them to sign.
To expedite your scheduling, please return all documents by email (info@clearpassage.com) or fax (1-352-336-9980) within 48-72 hours.
Optional: You may wish to review these additional forms, which will be required after you schedule.
- Privacy Policy
- HIPAA Consent (Clear Passage Therapies Inc.) Depending on the location you choose to attend, we may send you an additional HIPAA consent form required for that location.
- Informed Consent
- Financial Agreement
- You will receive a condition-specific research survey after you have scheduled therapy.
If you have not yet done so, please complete a Comprehensive Medical History Form.
Clearance forms are required as part of your application for therapy. Please print and bring this form to your physician for them to sign. The form indicates any contradictions or cautions that we need to be aware of, in order to treat you safely.
If you’d like a free consult, please take 20 minutes and fill out this form and we can determine if therapy would be a good fit for you.
