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Patient Intake Form

This is the patient intake form for Kirk Integrative Physical Therapy. Before your first appointment with us, please complete and electronically sign this form and click Submit at the bottom when finished!

Date of Birth
Month
Day
Year
Gender (check all that apply)
Do you want your treatment notes sent to this provider?
Yes
No
Are you currently pregnant?
Yes
No
Severity of this condition
0 - No problems
1
2
3
4
5
6
7
8
9
10 - Unbearable

Type name to indicate signature

I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document.

THE CLINIC

1707 F Street

Bellingham WA 98225

360-202-6739

Appointment Hours:

Tue - Thu: 11am - 6pm ​​

Fri - Mon: Closed

F Street Clinic - Where to Park.jpg

CONTACT

Get in touch

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