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. Once you complete the form, read the important message for you below before submitting the form to start your healing!

    Contact Information

    Information We Need For Billing

    Information We Need For Billing

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


    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.

    By submitting this registration you are acknowledging our cancellation policy and agree to our terms and conditions.

    Once you submit this form the next screen will ask for your credit card information. You will not be charged any fees when you register. We will ONLY use the credit card to bill you if our cancellation policy is not followed. The card is stored in our secure server and is encrypted for total security.

    Thank you for following our systems that allow us to give the best quality and convenient care possible.

    Oh, if you already gave us your credit card information over the phone, it has already been stored in the secure server. In the next screen just click on the link that says you already gave us your credit card information.

    We look forward to seeing you!