Seating & Mobility Appointment Request
MUST BE FILLED OUT COMPLETELY.  This form will be routed, insurance is verified and a prescription is requested from your listed physician.  Once that form is complete you will be contacted to schedule an appointment.
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Today's Date *
MM
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DD
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YYYY
Are you a NEW client to Joliet Easterseals? *
CLIENT NAME *
CLIENT DOB *
MM
/
DD
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YYYY
GENDER *
RACE *
Client Diagnosis *
Allergies *
Client's most RECENT height and weight *
Legal Contact/Guardian Name.  (include relationship to client) *
Legal Contact/Guardian Phone *
Client's current address.  Please include city & zip *
Best EMAIL to contact.  SCHEDULING AND MOST COORESPONDENCES ARE DONE VIA EMAIL.  Please check your email for dsanchez@joliet.easterseals.com *
Physician's name
(We need this to get the prescription for you)
 *
Physician Contact Information
(Please include town & zip where seen)
 *
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