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.
Patient Details
Child's Name

First NameLast Name
Child’s Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex

Other
Diagnosis (if known)
Reason for referral
Which service(s) are you seeking for your child? Select all that apply.

Other
Referring Physician Information
Referring Physician Information
Pediatrician's name

First NameMiddle NameLast Name
Practice name and location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Physician, if different from your child’s pediatrician

First NameMiddle NameLast Name
Parent or Guardian Contact Information
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.
Secondary Email
example@example.com
Secondary Contact Information
Secondary Contact's Name

First NameMiddle NameLast Name
Partner/Spouse/Secondary contact name

First NameMiddle NameLast Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Partner/Spouse/Secondary contact email
example@example.com
Insurance Information
Insurance Company
Policy Holder

First NameMiddle NameLast Name
Policy Holder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Child
Member ID (Child's ID)
Group Number
A quick photo tip: To help us process your child’s referral as quickly as possible, please place the insurance card on a flat surface in good lighting and center the entire card in the photo. Make sure all four corners and the text are clearly visible, and try to avoid glare, shadows, or cropped edges. Thank you!
Front of Child's Insurance Card

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Back of Child's Insurance Card

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Medical Documentation
Upload Prescription

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Upload Medical Notes from your child’s most recent appointment

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Consent & Acknowledgment
Consent Statement
I have read, understand, and agree to the above statements.
Parent Signature
Should be Empty:

Patient Details

Referring Physician Information

Parent or Guardian Contact Information

Secondary Contact Information

Insurance Information

Medical Documentation

Consent & Acknowledgment