New Patient Forms

For your convenience, please find below our patient forms to print and complete prior to your initial evaluation. If you would prefer to complete the forms in our office, please plan to arrive 15-20 minutes before your scheduled appointment to allow enough time.

pdfPatient Information Form

pdfMedical History (Page 1/2)

pdfMedical History (Page 2/2)

pdfMedication List

pdfStatement of Financial Responsibility

pdfPrivacy Notice

pdfAppointment Cancellation Policy

pdfPatient Health Questionnaire (PHQ-9) - Medicare Patients Only

Please select the outcome measure below that best applies to your condition:

pdfDizziness Handicap Inventory (Vertigo)

pdfJaw Functional Limitation Scale (TMJ)

pdfLEFS (Hip, Leg, Knee, Foot, Ankle)

pdfNeck Disability Index

pdfOswestry Back Disability Index

pdfQuickDASH (Shoulder, Elbow, Arm)

pdfWrist/Hand Functional Scale

Insurance

NO REFERRAL NEEDED!

In Pennsylvania, you can be treated without a referral from your physician by a physical therapist with a Direct Access License. Ditzler Physical Therapy is Direct Access certified, and, as a healthcare consumer, you have the right to choose your physician, your hospital, and your physical therapist.

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Call for an Appointment

(717) 820-4979

114 East Main Street
Fredericksburg, PA 17026
FAX: (717) 820-4972

Office Hours:
Mon, Weds, Thurs: 8-7
Tues & Fri: 7-12
Sat: By appointment only.