Abundance - Prosperity - Longevity

Medicare Functional Questionnaire for Back

New patient Intake form - Cash  




Insurance patients:

Medicare patients:

Please follow this link and fill-out the patient registration:                         

then dowload and complete the appropriate forms below.

You can return the completed forms:

  • in person during your first visit, 

  • via e-mail: Info@brighton90210.com ,

  • or via fax: (310) 201-1604

Lower Extremity Questionnaire

To ease the registration process and meet insurance requirementS, PLEASE provide the following documents BEFORE your initial visit:


  • A Prescription from your Doctor for Physical therapy treatments 

  • A valid ID

  • Your Insurance card

  • completed registration forms (see below for downloads)


New patient Intake form - Insurance  




Forms

Medicare Functional Questionnaire for Neck

Lower Extremity Questionnaire

Physical Therap​y

Pilates Studio, Fitness training



Lower Extremity Questionnaire

Medicare Functional Questionnaire for lower extremity (Hip - Knee - Ankle/Foot)

Medicare requires patients to complete a functional assessment questionnaire. Please download and complete one or more of the following forms as they relate to the area(s) to be treated

Cash patients:

Lower Extremity Questionnaire

New patient Intake form - Medicare                                             

































Medicare Functional Questionnaire for upper extremity (Shoulder - Elbow - Wrist/Hand)