Check Benefits

Check My Benefits

Magnolia Physical Therapy & Wellness, Inc
This is a HIPAA compliant platform.

Please fill out the following information and our office will call you back to inform you of your financial responsibility for therapy services.
Prospective Patient Name : *

First NameLast Name
Phone Number :

Area CodePhone Number
Email:
By providing your e-mail you are agreeing to receive messages regarding scheduling and billing. Magnolia does NOT mail newsletters / promotional material/ nor share your e-mail with others.
Date of Birth :*

MonthDayYear
Date
Address Where Therapy is To Take Place :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance Name :
Insurance Information (i.e. Group #, Member ID #)
Insurance is :
Phone Number for Providers (usually on the back of the card)

Area CodePhone Number
Supplemental Insurance :
If you don't have one, leave blank
Insurance Information (i.e. Group #, Member ID #)
Name of the doctor we will request orders from:
First and Last Name OR Last Name and Practice Name.
Optional Message :
Interested in :

Physical TherapyOccupational Therapy (Decatur or Telehealth only)Personal Training (Wellness)
COVID-19 Screening
Do you have any symptoms of COVID-19 not caused by another condition?

YesNo
Have you been exposed to someone with COVID-19 in the past two weeks?

YesNo
Have you tested positive for COVID-19 in the past two weeks?

YesNo
Has a healthcare professional or public health official told you to self quarantine in the past two weeks ?

YesNo
Have you had the Covid-19 Vaccine?

Yes, first dose.Yes, first and second dose.No.I wish to not respond.
Should be Empty:

Check My Benefits

COVID-19 Screening