Infant Physical Therapy Screening Form

Infant Physical Therapy Screening Form

Infant Physical Therapy Screening Form

If you are interested in having your child screened for physical therapy services at the Schreiber Center, please answer the questions below.

Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email Address*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is the best time of day to reach you? *

Child's Name*

First NameLast Name
Child's Age*
Child's DOB*

MonthDayYear
Date
My child suffers fromGERD or reflux.My child has a medical condition.My child has allergies.Other
Is there anything else you'd like us to know prior to scheduling (indicate n/a if not)? *

Please indicate your preferred days and times for a screening (select all that apply).*

Rows	Monday	Tuesday	Wednesday	Thursday
7:30 am to 11:30 am
11:30 am to 3:30 pm
3:30 pm to 7:00 pm

YesNo
YesNo
Signature*

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Date*

MonthDayYear
Date
Thank you for completing the Infant Physical Therapy Screening Form. Once you hit submit, you'll be redirected to a payment page to collect the $25 screening fee. If you have any questions, pleae reach out to Libby Crockart at ecrockart@schreiberpediatric.org
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