Verification Form
Please print this page and take it with you for your visits. Complete it before you leave, then bring it on your first day of PT100.
This is to verify that the following individual:
Visited this site (name of site):
At this address:
On the following dates:
Total Hours:
Write a brief statement as to the type of physical therapy observed, and any other information that is appropriate with respect to the observation experience.
Signature of individual:
Signature of Physical Therapist/Physical Therapist Assistant: