New Client - Rehab (Cash Pay)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Location - City, State
*
How did you hear about us?
*
Please Select
Google
LinkedIn
Word of Mouth
Instagram
Facebook
Are you currently experiencing pain or discomfort? Describe the location and intensity (0 best - 10 worst).
Have you seen a healthcare provider for your current problem?
*
Yes
No
Appointment has been scheduled
Are you covered by any health insurance plans? While we specialize in cash-based therapy, it's always helpful to know if you have insurance coverage that may provide reimbursement.
Availability for offered services
Morning: 8-11
Afternoon: 12-4
Evening: 5-8
Please note: Georgia direct access laws require a physician's referral to continue PT after 8 visits or 21 days, which ever comes first. Understood?
*
Yes
No
Submit
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