Coach House Physical Therapy

Serving the community for over 22 years!

17453 Jefferson Davis Hwy. · Dumfries, VA 22026 | Ph: 703-221-3913 · Fax: 703-221-3203 · Billing: 703-221-3931

New Patient Forms

Notice to patients: In order to better serve you, please arrive 20 minutes before your scheduled appointment. This allows time to add patients into the system and verify insurance requirements. In addition, please have ready your prescription and if your insurance company requires it, your referral.

If able, you may scan and e-mail your forms to us ahead of time at, and we will get you in our system ahead of your appointment.


Intake Form 1 - Electronic

Intake Form 2

Notice of Privacy Practices

List of Medications

Insurance Information Form

1. Neck

2. Lower Extremities (Hips, Legs, Ankles, Feet)

3. Upper Extremeties (Arm, Shoulder, Hand)

4. Knee

5. Back