If you are visiting Glinn & Giordano for the first time, we will need to get some information from you before we proceed with your rehabilitative care. We have tried to streamline our processes so that you have very little, if any, wait prior to your appointment. If you have access to a printer, simply print out the forms below and complete them prior to your first visit.

Patient Information Form: This form is a general information sheet that we use to input information into our computer systems about your current injury, medical history, insurance information as well as specific personal information relating to you.

Handwritten forms:

Patient Information Form 1 of 2

Patient Information Form 2 of 2

OR

Computer typed forms:

Patient Information INTERACTIVE Form 1 of 2

Patient Information INTERACTIVE Form 2 of 2

HIPPA Form: This form is a general form that informs you about our records release policy, advanced beneficiary notice (ABN) and to meet the guidelines set forth in the Health Insurance Portibility and Accountability Act (HIPPA).

HIPAA-ABN Form

Prescriptions:

This is our G&G Physical Therapy prescription.  If you are a doctor’s office and need more Physical Therapy prescriptions in your office, contact Connie House at 661-327-4357 and she will get a new pad of prescriptions to you.  In the meantime, feel free to download our prescription using the below link until we get you your new prescription pad.

Prescription

If you have any questions or need assistance completing the forms, please feel free to contact us and we will assist you in any way possible.