Prior to your first visit with Prairie Rehabilitation please complete the downloadable forms listed below. Options for submission include fax, mail or turn in at the time of appointment. For a complete New Patient Forms packet please click the downloadable PDF. If you would like assistance in filling out your New Patient Forms please call one of our outpatient clinics listed under the locations tab.
Please print and fill out all of the following forms prior to visiting us.
- New Patient Intake Forms
- Privacy Policy Statement (Read Only)
And one of the following forms:
- Women’s Health Intake Questionnaire (complete for pelvic pain or incontinence diagnoses)
- Men’s Health Intake Questionnaire (complete for pelvic pain or incontinence diagnoses)
- Wheelchair Intake Questionnaire (complete if you are being seen for a wheelchair fitting)
- Lymphedema Questionnaire (complete only if you are being seen for lymphedema)
- ALS Questionnaire (complete only if you are being seen for ALS)
If you have a question of what forms to use place contact any of our outpatient clinics listed on the locations tab or call our main business office at 605-334-5630.