New Patient Intake

New Patient Intake

Welcome to Power of Movement Pediatric Therapy! Please complete this secure form. Once the form is submitted, a member of our office team will contact you within two business days to discuss the next steps.
Child's Name

First NameLast Name
DOB

MonthDayYear
Sex
Diagnosis (if known)
Reason for referral
Pediatrician's name

First NameLast Name
Practice name and location
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Upload Prescription

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Upload Medical Notes from your child’s most recent appointment.

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Referring Physician, if different from your child’s pediatrician
Which service(s) are you seeking for your child? Select all that apply.
Parent's contact
Parent/Guardian's Name

First NameLast Name
Relationship to Child
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Insurance
Insurance Company
Policy Holder

First NameLast Name
DOB

MonthDayYear
Member ID
Group Number
Relationship to Child
Upload front of insurance card

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Upload back of insurance card

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Consent & Acknowledgment
Thank you for taking the time to complete this form. We appreciate the opportunity to learn more about your child and look forward to reviewing the information you have provided.

By submitting this form, I certify that the information I have provided is true, complete, and accurate to the best of my knowledge.

I understand and acknowledge that:
- Submission of this form is a request for services and does not guarantee an appointment or acceptance as a patient.
- A therapist-patient relationship is established only after an evaluation has been scheduled and completed.
- Insurance coverage, prior authorization, claim approval, and payment are determined by the patient's insurance plan and cannot be guaranteed by Power of Movement Pediatric Physical Therapy.
- Additional information or documentation may be requested before an appointment can be scheduled.
I have read, understand, and agree to the above statements.
Consent
Parent signature
Consent
Acknowledgment
Should be Empty:

New Patient Intake

Parent's contact

Insurance

Consent & Acknowledgment