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Physical Therapy Associates of New York
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You are here: Home / Forms / Back Index
 

Back Index

Instructions

This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.

HIPAA Consent
Although this form is dual encrypted using SSL & GnuPG, there is the slight possibility that this communication can be intercepted in transmission, decrypted, or misdirected. Your use of email to communicate protected health information to us indicates that you acknowledge and accept the possible risks associated with such communication.

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19 West 21st St, Suite 404

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Physical Therapy Associates of New York

19 West 21st Street, Suite 404
New York, NY 10010

212 366-4450
info@ptany.com

Our Office Hours

M,W 11:00AM-7PM
T,Th,F 8:00AM-4PM

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