Patient Forms and Checklist


To help get you started on your path to recovery, please print and fill out the following registration forms. They are supplied in Adobe PDF format. You can get a free copy of the Adobe PDF reader (Adobe Acrobat) here. Please be sure to bring all forms completed with you to your first appointment.

Medical History
HIPAA Statement
Medication Log

If instructed by the office, please print out the relevant form:
Back Index / (Spanish)
DASH / (Spanish)
LEFS / (Spanish)
Neck Index / (Spanish)
Patient Summary Form 750 / (Spanish)


Please bring the following materials with you for your first visit.

Registration Forms above.
Insurance Card.
Drivers License or Picture ID.


Satisfaction Survey

After you have complete your therapy with Carlson Therapy Network, we would love to hear your feedback. Please take a moment to fill out our Patient Satisfaction Survey and send it back to us. You may mail it to:
Carlson Therapy Network
105 A Newtown Road
Danbury, CT 06810
or Fax to
(203) 739-0792