Online Submission of Client Information
Thank you for choosing Progress Physical Therapy for your care. We look forward to serving you.

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First Name:


Middle Name:


Last Name:


Street Address:


City:


State:


Zip:


Phone (best way to reach you):

   

Phone (first alternate):

   

Phone (second alternate):

   

Date of Birth:


E-mail (optional):


Emergency Contact:


Emergency Contact Phone:


Reason for Visit:


Date of Injury:


Date of Surgery:


Your Doctor:


How did you hear about us?


Known Medical Conditions:


Current Medications:


Insurance Company:


Insurance ID#:


Insurance Group#:


Name of Primary Insured:


Primary's Date of Birth:

By submitting this information, I understand that all fees are due when services are provided and that these services are considered Out-of-Network. I understand that the Progress office staff is available to assist with any questions or concerns regarding this policy.

When you submit your information, you will receive confirmation that your information has been transmitted.


Copyright 2008 Progress Physical Therapy, Inc. All rights reserved.