Forms, Insurance & Rights

New Patient Forms

New patients can save time during their first visit by completing and submitting the following forms online. Simply click on the form’s title to submit the requested information. Please note that all information submitted via these forms will be kept confidential as befits the nature of the contents.

Patient Information Sheet
Medical History (If you have a lengthy medication list, please bring it with you and we will make a copy)

New patients should plan to arrive 15 minutes early for their first appointment.

6 Turnpike Acres Road, Suite 2
PO Box 1047, Gray, Maine 04039

Tel: (207) 657-5600
Fax: (855)-464-0106
office@grayptcenter.com

Founding Members of:

Our Affiliate:
Premier Physical Therapy
316 Portland Rd
Bridgton, Maine 04009

Tel: (207) 647-2727

6 Turnpike Acres Road, Suite 2,
PO Box 1047, Gray, Maine 04039

Tel: (207) 657-5600
Fax: (855)-464-0106
office@grayptcenter.com

Our Affiliate:
Premier Physical Therapy
316 Portland Rd
Bridgton, Maine 04009

Tel: (207) 647-2727

Founding Members of:

Name	Reason (Pain, BP, Diabetes etc )	How Much (Mg)	How Often (per day or wk)	How Taken mouth, inject)

Name	Reason (Pain, BP, Diabetes etc )	How Much (Mg)	How Often (per day or wk)	How Taken (mouth, inject)

Name	Reason (Pain, BP, Diabetes etc )	How Much (Mg)	How Often (per day or wk)	How Taken (mouth, inject)

Forms, Insurance & Rights

New Patient Forms

Medications and Supplements

Emergency Contact

Your Employer

If Under 18 Years of Age:

BILLING / INSURANCE INFORMATION

If either of the Insurer’s listed above is Worker’s Comp or Motor Vehicle Accident related, please provide us with the Claim Handler’s Name, Telephone Number and your File / Claim Number.