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Orthopedic Evaluation | Level Up Rehabilitation Services
Level Up Rehabilitation Services

Orthopedic Evaluation

Share your injury history, pain, and movement concerns. Everything you enter goes directly to the clinic.

Patient InformationStep 1

Patient Information

Fields marked * are required.

Emergency Contact
Referring Provider

Chief Complaint & Pain History

Tell us about your symptoms.

No PainModerateExtreme
No PainModerateExtreme
No PainModerateExtreme

Aggravating Factors & Location

Where and when do you feel it?

Injury & Surgical History

Details of your injury and any past surgeries.

Current / Recent Injury
Previous Surgeries

Prior & Current Treatments

What have you already tried for this?

Medical History

Anything relevant to your care.

Functional & Lifestyle Status

How is this affecting your daily life?

No functionFull
No impactSevere

Goals for Treatment

What do you hope to achieve?

Cancellation & No-Show Policy

Please review and acknowledge.

SituationFee / Consequence
No-ShowFull session fee charged to card on file
Cancellation < 24 hours$50.00 late cancellation fee
Cancellation ≥ 24 hoursNo charge, thank you for the courtesy

No-show: failing to attend with no prior notice results in the full visit fee charged to the card on file. A written appeal may be submitted within 7 days for documented medical emergencies.

Late cancellation (under 24 hours): incurs a $50.00 fee regardless of reason, except documented emergencies reviewed case-by-case. This fee is not covered by insurance and is your direct responsibility. To avoid it, cancel at least 24 hours ahead.

To cancel or reschedule: online at levelupptdoc.com, phone (703) 637-8252, or fax (571) 617-0044.

By scheduling, you authorize Level Up Rehabilitation Services, LLC to charge applicable fees to your payment method on file. Fees are non-refundable except at management’s discretion.

Consent & Authorization

Please review and acknowledge below.

By submitting this form, I confirm that:

  • The information provided on this form is accurate and complete to the best of my knowledge.
  • I consent to evaluation and treatment by Dr. Grace Villaver, DPT, CLT, and the staff of Level Up Rehabilitation Services, LLC.
  • I understand that orthopedic rehabilitation may require multiple sessions and an active home exercise program.
  • I authorize communication and coordination of care with my referring or treating providers as needed.
  • I have been given the opportunity to ask questions and understand I may withdraw consent at any time.

Review & Submit

Please review your responses, then submit. Your evaluation goes directly to Dr. Grace.

Thank you. Your evaluation is complete.

Your intake is complete and on its way to Dr. Grace’s office.

Your privacy, protected

For your privacy, your copy is shown here only once and is not saved on any website. Please download it now and keep it somewhere safe. The file is password protected: open it with your date of birth as 8 digits in year, month, day order (for example 19900215 means 15 February 1990). A copy has also been sent securely to Dr. Grace’s office.

Call (703) 637-8252

The download is a single secure file. Open it in any web browser and enter your date of birth.

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