Integrated Physical Therapy

(608) 658-5352

Fax: 1-888-965-4018

Contact Us:

Dee Aussprung


Dee Aussprung
Heather Hartwig Stokes
Kate LaZotte
Sarah Voung
Peggy Hojem



Evaluation Forms



Integrated Physical Therapy


Please print and complete these forms in their entirety prior to your first appointment. Your atention to accuracy in completing these forms will allow us to bill your insurance company correctly.

This will allow us to spend more focused time on your treatment during your first visit. Please bring these 4 forms with you along with your insurance identification card (s).

Evaluation Forms

Standard Forms

United Health Care Form (For UHC patients Only)

Patient Health History UHC Patient Summary
Treatment Agreement Back Musculoskeletal Screening Tool
Privacy Notice Form  
Patient Information Form  


Insurance Verification

Fill out this form if you prefer to call your insurance with your specific coverage details.

Insurance Verification



2275 Deming Way Suite B 100 Middleton, WI 53562