PIM Scheduling Form
Please provide the following information so we can schedule your appointment. Patients ages 18 AND OVER MUST SCHEDULE THEIR OWN APPOINTMENTS unless they are unable. In which case their legal guardian may fill out this form.

Only fill out this form ONCE so we can create your profile for scheduling purposes. If you have already filled it out and need to schedule another appointment, please email info@philly-im.com.

Email address *
Name (as listed on your insurance / Medicare card) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Male or Female? *
Mobile Number *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Type(s) of Health Coverage *
It is important to include any primary and secondary providers for testing purposes.
If you have healthcare coverage, please list your carrier.
Your answer
How did you hear about us? *
If a person referred you, please give us the name of that person so we can thank them. If you chose "other" please elaborate.
Your answer
What type of appointment would you like to schedule? *
Free Consultations are available with Annemarie McManus, MMSc, PA-C, PT, IFMCP only. The Free Consultation can be done by phone or in-office and is optional. The consultation will allow time to ask treatment questions and talk about your health goals to our providers to help decide if you are ready to become a patient. Because you are not a patient at this time, our providers do not review medical records, give medical advise, or start treatment at this time. A New Patient Appointment can be done in-office only. This is when you begin your personalized treatment plan. We require a $300 deposit at the time of scheduling a New Patient Appointment. Free Consultations are currently being scheduling on Wednesday and Thursdays in late October. Annmarie is scheduling New Patient Appointments in late October. Dr. Tetlow is scheduling New Patient Appointments in mid-December.
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