Patient Intake Forms

Patient Intake Forms

At Franklin Rehab, we want to maximize your time with us. Prior to your first visit, please follow the steps below:

 

In-Clinic or At-Home Visit:

Click on the applicable form below, fill out and submit online.

New Evaluation Form – English / Spanish

 

Virtual Visit:

Click on the applicable forms below, fill out and submit online.

New Evaluation & Consent Forms

Medicare & Self-Pay Program

Existing Patient Virtual Visit Consent

 

Notice of Privacy Practices

Notice of Privacy Practices – English / Spanish