Physical Therapy Callback Request Form

Streamline Your Physical Therapy Patient Intake with a Professional Callback Request Form

When potential patients reach out to your physical therapy clinic, making a great first impression is crucial. This Physical Therapy Callback Request Form template helps you capture all the essential information you need to provide excellent service from the very first interaction.

Perfect for Physical Therapy Clinics and Rehabilitation Centers

Whether you're a solo practitioner, a multi-location physical therapy practice, or a rehabilitation center, this form template is designed specifically for healthcare providers who need to efficiently screen and schedule new patients. By collecting injury details, physician referral information, and insurance pre-authorization status upfront, you can:

• Reduce phone tag by gathering complete information before the first call
• Verify insurance coverage early in the process to avoid billing surprises
• Prioritize callbacks based on injury type and urgency
• Prepare your team with relevant patient history before making contact

How This Form Supports Your Workflow

This callback request form captures everything your front desk and clinical team needs: patient contact information, injury type and location, pain level, referring physician details, insurance provider, and pre-authorization status. You can embed this form on your website, share it via email, or link to it from social media to make it easy for patients to request consultations.

Once a patient submits the form, you can use Stepper to automatically route the submission to the right team member, create a patient record in your practice management system, send confirmation emails, and even trigger insurance verification workflows. This automation means less manual data entry and faster response times for patients who need your help.

HIPAA Considerations

Please note that while Paperform offers robust security features including SOC 2 Type II compliance, Paperform is not HIPAA compliant. This form template is designed for initial contact and scheduling purposes only. Avoid collecting protected health information (PHI) beyond what's necessary for callback scheduling until you've established a secure, HIPAA-compliant communication channel with your patient.

Physical therapy practices, rehabilitation centers, sports medicine clinics, and healthcare providers trust Paperform to create professional, conversion-focused forms that help patients get the care they need faster.