New Patient Intake Form

Your information is secure and stored on an encrypted server with limited access only by our administrators. We value your privacy and take all measure to ensure your security.

Contact Information

Name *

(First Name)

(Last Name)

Street Address 1 *

City *

State *

Postal Code *

Email *

Home Phone *

Cell Phone

Cell Phone Carrier

Fax

Information We Need For Billing

Date of Birth "mm/dd/yyyy *

SSN *

Additional Information We Need

Physican phone (if unknown, name city he or she is in)

Emergency Contact Name *

Emergency Contact Phone *

How did you hear about us? If you were referred by someone, please put their full name here *

On Which Body Part(s) Do You Need Treatment? *

Back	Neck	Elbow
Shoulder	Knee	Hand/Wrist
Ankle	Foot	Other

Cancellation Policy

We value your time and ours. Each and every appointment for physical therapy is important for your optimal recovery. A no show or late cancellation by you or another patient affects the care of someone else. You MUST cancel 24 hours before your appointment time by calling us at 856-751-8881 to avoid a cancellation fee of $40 for the missed treatment appointment and $100 for a missed evaluation. We understand medical emergencies and personal / family illnesses can happen. Proof of these incidences as the reason for the missed appointment will exclude you from the $40 fee for the treatment and $100 fee for the evaluation.

This policy assures that you and all other patients have access to as many open appointment times as possible to accommodate your scheduling needs and optimize your convenience.

Credit Card number

Expiration Date mm/yy

Want to input Credit Card information online for cancellation policy *

	Yes
	No

Click yes if you want to input your credit card information for your convenience

Click no if you would like to bring in your credit card and have us store the numbers offline

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