New Patient Forms in Accessible Format

You do not have to fill this out alone

The paper packet has to be signed by hand, and we know that is not workable for everyone. If you would find it easier, our front desk will go through the entire packet with you and complete it for you, either on the phone before your visit or in person when you arrive. There is no charge and you do not need to explain why.

Call (408) 366-1735 and tell us you would like help with the new patient forms. If you would rather write, email info@peakptcupertino.com. Please give us a call before your appointment if you can, so we can set aside the time.

What to expect at your initial evaluation

Arrive at least 15 minutes before your initial evaluation. That gives you time to check in, review your insurance benefits, and finish any additional paperwork, so you get your full treatment time with your physical therapist.
Your initial evaluation is up to one hour, one-on-one with the physical therapist. At follow-up appointments the first half is generally with the physical therapist and the second half is exercises with a physical therapy aide.
During the evaluation your physical therapist reviews your medical history, current complaints, functional limitations and goals, then assesses your posture, range of motion, strength and functional biomechanics. You and the therapist build the treatment program together.

What to bring

Your completed new patient forms
Your insurance card or cards, and photo ID
Your referral or prescription from your doctor, if you have one
Your calendar, for scheduling future visits

Wear loose, comfortable clothing. You will begin exercising at the initial evaluation. If you are coming in for a shoulder, bring a t-shirt or tank top. If you are coming in for a knee, bring shorts.

Patient information

The packet collects the following. If you have been here before and nothing has changed, each section has a box you can check instead of writing it all again.

Section 1: Patient demographic information

If none of this has changed since your last visit, you can check the box at the top of the section instead of filling it in again.

First name and last name
Date of birth
Address, city, state and ZIP
Sex
Marital status
Cell phone, and whether you consent to text messages
Home phone and work phone
Email address

Section 2: Primary insurance subscriber information

This is the person whose name the insurance policy is under. It may be you. If nothing has changed since your last visit, you can check the box instead of filling it in again.

Subscriber first name and last name
Subscriber address, city, state and ZIP
Subscriber sex
Subscriber date of birth
The subscriber’s relationship to you

Section 3: Emergency contact

Name
Relationship to you
Phone number

Section 4: Other

Name of the doctor who prescribed physical therapy, if you have one
How you heard about Peak

Section 5: Disclaimers you initial

On the paper packet you write your initials next to each of these, then sign and date the bottom of the page. The full text of each is below.

Consent to treatment: I consent to rehabilitation and related services at Peak Physical Therapy. In doing so, I understand that such rehabilitation and related services may involve bodily contact, touching, and/or direct contact of a sensitive nature.
Treatment of minors: I, as parent or guardian of a minor receiving treatment, understand and agree that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulted from failure to do so.
Liability: I know and agree that Peak Physical Therapy is not responsible for loss or damage to personal valuables.
Waiver and release: I release Peak Physical Therapy from all liability, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service, emergency medical technician, physician or urgent care services.
Authorization of payment: I assign all benefits directly to Peak Physical Therapy and authorize release of any medical records necessary to facilitate my treatment to process medical claims. I understand that in the event my insurance company does not pay for the services I receive, I will be financially responsible for payment.
Notice of privacy: I acknowledge receipt of the Peak Physical Therapy Notice of Privacy Practices.
Returned check policy: A $25 fee will be issued for a returned check of non-sufficient funds.
Collection fee, attorney fees and interest: I agree to pay interest at the rate of 18% annually on all past due balances from the original due date, plus court costs and reasonable attorneys’ fees, with or without suit, incurred in collecting any past due balance, and a collection fee of up to 40% of the principal balance if my account is assigned to a collection agency.

Medical history

This page asks for:

Your name and the date
Your height and weight
Whether you are presently taking any medications, and a list of them if so
Whether you have any allergies, and a list of them if so
Whether you have ever been hospitalized or had surgery, and if so when and for what
Whether you have participated in a physical therapy program before, and if so when, how long, and for what
Anything else you feel would be useful for our staff to know

You are also asked to mark yes or no for each of the following conditions, indicating whether you have had it or have it now:

High blood pressure
Dizziness
Chest pain
Osteoporosis
Heart attack
Lung disease
Pacemaker
Tuberculosis
Diabetes
Smoker
Seizures
HIV positive or AIDS
Stroke
Hepatitis
Cancer
Epilepsy
Asthma
Joint replacement or pins
Major illness or major accident
Bladder problems
Reaction to chemicals
Kidney disease
For women: could you be pregnant now

Appointment cancellation and no-show policy

Patients who attend all their physical therapy visits are 93% more likely to fully recover from an injury, and those who miss even one visit have a lowered potential for recovery. To keep others from waiting for their care, we need your compliance with this policy. You sign at the bottom of this page to indicate you understand it.

Arrive on time. We strive to start on time, so arrive for your scheduled appointment on time.
If you are running late, contact us as soon as you know. We will check with your provider to make sure there is enough time to provide the care you need.
- If you are more than 15 minutes late, your session may need to be rescheduled and the missed visit policy applies. Chronically late patients will be asked to change their appointment times.
- Medicare requires a certain amount of direct supervision by a physical therapist per appointment. If a Medicare patient arrives more than 10 minutes late we cannot keep the appointment, and the patient is charged a $40 missed appointment fee.
If you are sick, contact us as soon as you have symptoms. Do not wait for the day of your appointment. We will give you a plan for what happens next.
- For example: if you are sick on Monday but your appointment is Wednesday, let us know Monday.
To cancel or change an appointment, give us at least one business day of notice. Without that notice you will be charged a $40 fee. Tuesday through Friday appointments must be canceled at least 24 hours ahead. Monday appointments must be rescheduled or canceled at least 72 hours, or 3 days, ahead.
- We send courtesy text and email reminders, but we strongly encourage you to set your own reminders rather than rely on that technology, because it can have issues.
- Enough notice lets us reschedule you and get another patient in for care.
- The fee is your responsibility and is due at the time of your next visit.
Repeated same-day cancellations or no-shows move you to the waitlist. Patients with multiple same-day cancellations or no-shows are removed from the active schedule and placed on our waitlist, so that last-minute cancellations do not keep other patients from care.

Business hours

Contact the office during business hours at least one business day before your appointment for any illness, appointment change, or cancellation.

Monday: 8:00am to 7:00pm
Tuesday: 7:00am to 7:00pm
Wednesday: 7:30am to 7:00pm
Thursday: 7:00am to 7:00pm
Friday: 7:30am to 6:00pm
Saturday, Sunday and holidays: Closed

The questionnaire pages

The last pages of each packet are standardized questionnaires used across physical therapy to measure how your symptoms affect daily activity. Which one you get depends on the packet:

Back injury: Modified Oswestry Low Back Pain Disability Index
Neck injury: Neck Disability Index
Hip, knee and ankle injury: Lower Extremity Functional Scale
Shoulder, arm and hand injury: QuickDASH
All packets: Patient Health Questionnaire, form PHQ-202

These are published by outside organizations, so they are not reproduced here. Your therapist or the front desk will go through the questions with you at your visit. It takes a few minutes and there is no preparation needed.

Notice of Privacy Practices

The packet includes our Notice of Privacy Practices, which describes how your medical information may be used and disclosed and how you can get access to it. It is also available on its own as a tagged, screen-reader-friendly PDF: Notice of Privacy Practices.

The printable packets

If you would rather print and fill out the packet by hand, the download links are on the New Patients page. This page and the printed packet ask for the same things.

New patient forms in accessible format