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Intake Forms

Please start by clicking the link below to access our electronic Business Associates Agreement.
Please note that this document opens in a separate window. After signing, please return to this page to continue the intake form.

After completing this form please complete the remaining fields at the bottom of this page.

Step 1 of 3

Sign by Printing Your Full Name:
Name*
*
- I agree that the printed name above is recognized as my authorized signature.*
*
- I have read and agree with the following documents: HIPAA Notice of Privacy Practices, Assignment of Benefits Form, Timeliness Policy, Informed Consent, and Transportation Policy.*
Select your location:
Location:*
Select your Service:
Select your Service:*
- Physical Therapy
- Acupuncture