Patient Registration
Thanks for choosing Change Sports Physical Therapy for your rehabilitation need! We are excited to get you started on the road to recovery. We've tried to make this registration process as easy and quick as possible.

This form is secure and abides by HIPPA patient privacy standards.

Patient Information
Patient's Name *
Your answer
Email Address *
Enter the email you would like associated with this patient's record. You will also receive communication regarding care through this email if you select below in the communication preferences.
Your answer
Best Phone Number *
Your answer
Is this a mobile number? *
Is the patient a minor? (Under 18 years old) *
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Marital Status *
Emergency Contact
Name of person for Emergency Contact *
Your answer
Relationship of Emergency Contact to Patient *
Your answer
Phone Number of Emergency Contact *
Your answer
Employment Information
Employer *
Your answer
Employer Phone Number *
Your answer
Occupation *
Your answer
City of Employment *
Your answer
Referral Source
How did you find our clinic? Check all that apply *
Required
If you have seen a doctor for this condition, please list their name here
Your answer
Payment Agreement and Consent for Treatment
All Co-Payments are due on the date of service, unless arrangements have been made with the administration.

It is important you understand that you are personally responsible for the payment of all services rendered here. As a courtesy, we will bill your insurance if you provide the appropriate information. We advise you to contact your insurance company and ask about the physical therapy benefits for the plan you currently have.

By checking "I Agree", I agree to the statements above regarding payment of services. I also consent to receiving physical therapy treatment. I also herby authorize the release of my medical information necessary to process the claim and authorize the payment of medical benefits to Change Sports Physical Therapy Institute *
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