Pediatric Physical 
Therapy Inc.
Patient Forms
 Click to download

Welcome Letter for New Patients
Patient Information Form


Health History Form 

Financial Policies Form

Consent Form

Equipment/Home Modification Intake Form

Concussion Clinic Intake Form

Release of Liability and Indemnity Form for UpReach Hippotherapy Riders
Emergency and Photo Authorization Form for UpReach Hippotherapy Riders

We are currently providers for the following insurance plans:

New Hampshire Medicaid/Healthy Kids
Katie Beckett Waiver Program (HCCSD)

Well Sense

NH Healthy Families
Harvard Pilgrim


This is not an exhaustive list.  Please call if you have questions about your plan

134 Hall Street Suite #1 Concord, NH 03301
Phone: (603) 224-4540     Fax: (603) 228-7384