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CFC PT/OT Clinic Interest Form
***If this is a medical or mental health EMERGENCY, or if you have been the victim of a crime, PLEASE DIAL 911 OR VISIT THE NEAREST EMERGENCY ROOM.*** 

CFC Physical/Occupational Therapy Clinic occurs every month. The PT/OT Clinic offers tests, labs and referrals. Some commonly treated symptoms include: chronic back pain, joint pain, carpal tunnel, hand pain, upper and lower extremity disorders and more. If you would like to be contacted for an appointment during the next PT/OT clinic, please provide responses to the questions below (this information will not be shared and is for internal use). People will be contacted in the order that requests are received.
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First and Last Name *
DOB
MM
/
DD
/
YYYY
Phone Number *
Email *
Address (Street name, City, State, Zip)
 *
Are you a Franklin County Resident? *
Marital Status *
Preferred method of contact *
Who is your emergency contact & what's their relationship to you?
 *
Emergency contact number
 *
Race (Check all that apply) *
Required
Are you Hispanic/Latino? *
What is your preferred language? *
Would you like an interpreter for this visit? *
Residency Status *
Employment *
Insurance Status *
Type of housing *
How many people live with you? *
Yearly Income *
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