Patient Documents

Instructions

Do the following steps once you have called the office to secure an appointment time. 


1. Download and fill out the following forms:

  • Intake Pages 1 and 2
  • Medical History 
  • Direct Access (only if you do NOT have a physician referral)


2. Once the forms have been filled out and saved, email all documents to diazolsonpt@gmail.com


The following documents must be attached in the email:

  1. Intake Pages 1 and 2
  2. Medical History
  3. Direct Access OR Physician Referral
  4. Insurance card (Front AND Back)


3. Wait for an email confirmation that everything has been received. If you do not receive confirmation within 24-48 hours, please call the office at (408) 245-3574. Operating hours may vary due to COVID-19.

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Patient Intake Forms

If you have Medicare insurance, please fill out BOX-12 ONLY on the Medical Insurance Form. 

Only your signature and signature date is needed. All of the other information will be extracted from your intake forms.

Please include this form in the email along with the other documents required to finalize your scheduled appointments. 

Intake Pages 1&2 (pdf)

Download

Medical History (pdf)

Download

Direct Access (pdf)

Download

Medicare Insurance Form (pdf)

Download