Scoliosis Intake Packet-Adolescent Form
New Patient Information
Patient name: *
Your answer
Patient date of birth: *
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Patient address (city, state, zip): *
Your answer
Patient (or parent) phone number: *
Your answer
Patient (or parent) email:
Your answer
Parent(s) name(s): *
Your answer
Parent address, phone and email (if different from patient):
Your answer
Which parent to be contacted for appointments/consultations? *
Which parent will be responsible for payment? *
Preferred way to contact you *
Payment Policy

Scoliosis Physical Therapy is now a participating provider with BCBSLA, Vantage Health Plan and Medicare. Please provide your insurance information below for us to check your physical therapy benefits prior to your visit.

If you we do not participate with your insurance, we will provide an invoice you may submit to your insurance carrier to file for repayment on your own.

You can also pay out of pocket for your visit. Please call us for an anticipated cost of your visit.

Any copayments, coinsurance or out of pocket cost will be due at time of visit. Please discuss with us ahead of time if you will need a payment plan option.

Forms of payment: Payment may be made by check, cash, Visa, Mastercard, American Express or Discover. (make checks payable to Ashley Pittman or Scoliosis Physical Therapy) You may also use your Health Savings or Flexible Spending account for payment.

By typing your name, you consent to our payment policy (if under 18, please include parent or guardian name also): *
Your answer
Do you plan on using your insurance?
Insurance carrier
Your answer
Member ID
Your answer
Insured name
Your answer
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