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Physical Therapy Appointment
Schedule Your First Session
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
/
Month
/
Day
Year
Services currently include ages newborn up to 20 years of age.
In Which Week of Pregnancy Was Your Child Born?
*
Child's Gender
*
Male
Female
Has Your Child Been Diagnosed With A Certain Condition?
*
Yes
No
Child's Medical Diagnosis
Kindly specify your child's diagnosis given by their doctor.
Does Your Child Use Any Assistive/ Adaptive Devices?
*
None
Crutches
Walker
Wheelchair
Orthosis (brace, splint, etc)
Prosthesis (prosthetic arm, leg, etc)
AAC device
Hearing aids
Other
Other Assistive/ Adaptive Device:
Kindly specify the device(s) your child uses if selected "other" above.
Is Your Child Taking Any Medications?
*
Yes
No
Child's Medications
Parent/ Guardian Name
*
First Name
Last Name
Parent/ Guardian Occupation
Parent/ Guardian Phone Number
*
Please enter a valid phone number to contact you via Whatsapp messaging.
Format: (000) 00-000-000.
What Are Your Main Concerns?
*
Choose Your Preferred Service
*
Outpatient Clinic Sessions (Location: Healthquarters, Achrafieh)
In-Home Sessions
Appointment
*
Book Your First Session
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