Forms

Before you visit, please take the time to download and fill out the appropriate form(s).
Adobe reader is necessary to view these forms. A free download is available at http://get.adobe.com/reader/.

Patient Questionnaire

Please take the time to download  and fill out the Patient Questionnaire Form.  The Questionnaire allows us to pinpoint your pains and makes the diagnosis and therefore, treatment that much quicker.  We are providing this form online because we recognize your time is valuable.  It is our hope that by offering this form to you online we will be able to minimize any wait.  Please click here to download the patient questionnaire form.

Physical Therapy Referral

If you are interested in physical therapy, take this form to your doctor to order your physical therapy. Please click here to download the physical therapy referral form.

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Contact Special Medical Services

800 11th Street
Charles City, IA 50616
Phone: (641) 228-6344
Fax: (641) 257-4339
Email: info@charlescityphysicaltherapy.com

Clinic Hours

Mon-Fri, 7:30am - 5:00pm