Appointment Intake
Fill the form below and we will get back soon to you for more updates and plan your appointment.
Patient Name
*
First Name
Last Name
Date of Birth
*
Please select a day
1
2
3
4
5
6
7
8
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10
11
12
13
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29
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31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2025
2024
2023
2022
2021
2020
2019
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2017
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2015
2014
2013
2012
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2009
2008
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2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Year
Gender
Please Select
Male
Female
Not willing to Disclose
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you ever applied to our facility before?
Yes
No
Parent/Guardian 1
*
First Name
Last Name
Lives with Patient?
*
YES
NO
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
OK to Text:
*
Yes
No
Parent/Guardian 2
First Name
Last Name
Lives with Patient?
YES
NO
Email
example@example.com
Phone Number
Please enter a valid phone number.
OK to Text:
Yes
No
Who referred you to Baby Bear Clinic?
Are you working with Physical or Occupational Therapy? If YES, with who or at what clinic?
Do you plan to use insurance?
*
YES
NO- we will Private Pay
INSURANCE CARD FRONT
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INSURANCE CARD BACK
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Acknowledgements
I certify that the above information is correct.
Signature
*
Please verify that you are human
*
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