Telehealth Consent & Intake Form
Sara Mikulsky Wellness Physical Therapy, PLLC
What is your full name? *
What is your date of birth? *
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DD
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What is your email? *
What is your phone number?
Emergency Contact and Phone Number *
By clicking "I Agree" below, you are certifying and agreeing that you are the only person who has access to this email account and that this email account is your account. This email should match the email of where you received the link form. *
Required
What is your state of residence? *
What is your main injury, problem, or function you would like to address? *
When did these symptoms begin? *
Please check all that apply.
By checking "I Agree" you have read the Telehealth Informed Consent Document located at this link https://drive.google.com/file/d/1qObZhgf7r_hNOYo1XKX17aKtEQ6VHsee/view?usp=sharing and agree to all terms posted in this document. *
Required
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