Patient Registration
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please provide a photo of your driver's license or photo ID
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Front
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Primary phone number
*
Please enter a valid phone number.
Primary phone number is a:
*
Home phone
Cell phone
Work phone
Other
Secondary phone number:
Please enter a valid phone number.
Secondary Phone Number is a:
Home phone
Cell phone
Work phone
Other
How would you like to receive appointment reminders?
*
Phone Call
Text Message
Email
example@example.com
If you have a copy of your physical therapy referral, please upload it here:
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Responsible Party
If under 18
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to patient
Insurance Information
Are you using insurance or will this be self-pay?
*
Insurance
Self Pay
Primary Carrier
*
Subscriber/Policy Number
*
Group Number
*
Relationship to Policy Holder
*
Self
Spouse
Child
Other
Please provide a photo of your insurance card
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Back
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Secondary Insurance
If applicable
Secondary Carrier
Subscriber/Policy Number
Group Number
Relationship to policy holder
Self
Spouse
Child
Other
Please provide a photo of your secondary insurance card
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Back
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I acknowledge the the above information is complete and accurate
*
Date
*
-
Month
-
Day
Year
Date
Submit
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