Striving for Excellence in Rehabilitation Care

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    Patient Intake Forms

    New patients are welcome to fill out required paperwork below and bring in on your first visit and begin your Physical Therapy Evaluation / Treatment right away!

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    ​All forms are in Adobe PDF format.  If you need to download the Adobe Acrobat plugin,

    please click here.

    • Patient Agreement Form

    • ​Patient Data Form

    • New Patient History Form

    • Physician Referral Form

    • Pain Scale Form

    • ​Patient Privacy HIPPA Awareness Form

    • ​Consent of Care & Treatment Form

    • Patient Credit Card Signature Form

    • New Patient Fax Cover Form

    Local: (352) 562-7772   Toll Free: 1-877-658-1433 

    Divine Therapy & Wellness, LLC.

    © 2013 Divine Therapy & Wellness, LLC. All rights reserved.

    (352) 562-7772

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    Monday -  Friday     7:00 am - 5:00 pm
    Saturday                   Closed
    Sunday                      Closed

     

    Schedule Appointments:

    Monday - Saturday 7am - 8pm

    Divine Therapy & Wellness, LLC.

    3300 SW 34th Ave.​

    Suite 124B

    Ocala, FL 34474

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    Toll Free: 1-877-658-1433

    Fax: (321) 400-1422

    ​E-mail: PT@divinetherapyandwellness.com

    ​Our Hours:

     

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