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New Patient Intake Forms-Required for Telehealth and In-Office Visits

Please print and fill out the following forms prior to your first appointment to expedite the registration process. 

Patient Personal Information
Acknowledgement of Notice of Privacy Practices
Patient Agreement
Practice Policies
New Patient Questionnaire
​Media Permission Form
​Cancellation and Missed Appointment Policy
​
Direct Treatment Services Disclosure

NEW!! COVID-19 Required forms for In-Office Visits Only


Please review and/or complete the following forms prior to your in-office visit. 
Covid-19 In-Office Visit Policies and Procedures
Covid-19 Policies Receipt and Consent to Treatment
Caregiver Health Screening Self-Assessment Questionnaire 


Feel free to also share this infographic with your child to help him/her prepare for a visit in our office. 

Referral Forms

Patients:
Print out our referral form and take it with you to your child's next appointment with his/her pediatrician or specialist. A signed referral is not necessary to begin treatment, but may be required by your insurance company. Contact us for specific requirements based on your medical plan.

Physicians:
Print out our referral form for immediate use.  Referrals may be faxed or e-mailed to our office or given directly to patients' parents/guardians to bring to their first appointment with us.

Pinnacle Kidz Pediatric Physical Therapy

Promoting Strength and Development for Infants and Children through Physical Therapy

1640 Valencia St., Suite #1C
San Francisco, CA 94110
Ph: 415-654-5324
Fax: 415-654-5327
Contact us
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    Pinnacle Kidz Pediatric Physical Therapy                                    1772 Church St., San Francisco 94131                                           415-654-5324  
  • Home
  • Services
    • Physical Therapy >
      • Torticollis
      • Gross Motor Delay
      • Orthopedic and Sports Rehabilitation
    • Developmental Support
  • About us
    • Our Team
  • FAQ
  • Office Forms
  • Contact Us