Thank you for choosing to receive outpatient therapy at St. Luke's Rehabilitation Institute; we look forward to working with you. Please choose the form(s) that correspond to the program you will be participating in to complete prior to your first visit and sign and date accordingly. By filling these forms out ahead of time, you will decrease the amount of time you would normally spend in the waiting room.

If you have any questions or need help with forms, please contact our admitting department at (509) 473-6869. 

Patient Admission Forms

All Patients Must Review And Complete: 

• Consent to Treatment 
• Patient Health Summary (Cardiac and Pulmonary patients do not need to complete)
• Patient Rights and Responsibilities 
• Your Privacy Rights 
• Infection Risk Travel Screen 
  

Pulmonary Rehabilitation Patients Must Also Complete:

• Pulmonary Health Survey
• Shortness of Breath Scale
  
• Patient Health Questionnaire - 9 (PHQ-9)
• COPD Assessment Test
  

Cardiac Rehabilitation Patients Must Also Complete:

• Cardiac Health Summary 
• Dietary Fat Screener 
• Patient Health Questionnaire - 9 (PHQ-9)
  

Incontinence Patients Must Also Complete:

• Pelvic Floor Questionnaire 

Pediatric Patients Must Also Complete:

• Parent/Child Health Assessment 
• Special Notice