I am the:
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Patient
Parent/Caregiver
Referring Provider
Other
Patient Name
*
First Name
Last Name
Patient Date of Birth
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Month
/
Day
Year
Date
Parent Name (if applicable)
First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact:
Email
Phone
I am inquiring about the following therapy services:
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Speech Therapy
Feeding Therapy (Infant -Adult)
Myofunctional Therapy
Occupational Therapy
Safe and Sound Protocol
Physical Therapy
Dry Needling
Craniosacral Therapy
Aquatic Therapy
Other (If other, please specify in comments section below)
How did you hear about us?
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Please Select
Doctor
Psychologist
Dentist
Orthodontist
Ear, Nose, Throat Doctor
School
Community Event
Friend/Family/Word of mouth
Internet Search
Instagram
Facebook
Fusion Therapist
Previous Patient
Current Patient
Arkansas Lactation
Mercy Lactation
Washington Regional Medical Center Lactation
Willow Creek Women's Hospital
Daycare/Preschool Teacher
What is your PCP's name?
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If you do not have a PCP, mark 'NA
Reason for seeking services:
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Insurance Information:
Insurance Provider (check all that apply)
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Blue Cross Blue Shield
Aetna
Cigna
Ambetter
Medicaid ArKidsA
Medicaid ArKidsB
TEFRA
Medicare
UHC/UMR
Other (If other, please specify in comments section below)
If you answered OTHER to any of the questions above, please specify:
Insurance Member ID/Policy ID number:
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