Sending Form

Pediatrics Patient Information Form - Private and Confidential

Patient Demographics

Do you have a follow up appointment scheduled?: *

How did you hear about Eagle Physical Therapy?

Parent or Guardian #1
Parent or Guardian #2

Closest Relative or Friend (not living with you):

What are your goals for physical therapy?:

Insurance Information:

Eagle Physical Therapy is committed to providing quality physical therapy at reasonable cost. It is our policy to collect all accounts receivable within 90 days from date of service.

For those patients with insurance coverage, we bill regularly. The patient retains ultimate responsibility for financial charges incurred as a result of treatment. Our staff is available for assistance with insurance billing questions. However, the patient is responsible to understand the specifics of their individual insurance coverage. The insurance contract is between the covered individual and the insurance company.