Printable Forms

The forms available through this page can be downloaded, filled-out (manually or type in the actual pdf file), and printed, giving you the ability to fill out the necessary paperwork before you visit our office. This will speed up your visit and help us treat you quicker. Our forms are available in the Adobe PDF format.

EVERY PATIENT must fill out form file number 1 named “Intake”. There are FIVE (5) pages within this downloadable file. ALL must be filled out completely. Please also read the HIPAA compliance policy under "patient privacy" in the “schedule an appointment” drop down menu before signing “Acknowledgement of Receipt of Notice of Privacy Practices” (one of the forms within form file number 1). If the patient is a minor, the authorization to treat a minor must also be filled out on form 1, form 3 for those patients who are being treated for a back problem and/or sciatica, and form 4 for those patients who are being treated for a neck problem.

After you have completed your treatment at Made to Move Physical Therapy, Inc., please feel free to fill out form 5. We always appreciate customer feedback and want to know how we’re doing to satisfy your needs as a client. Please mail back to:

Made to Move Physical Therapy, Inc.
615 N Nash St., Suite # 306
El Segundo, CA 90245