Mees Physical Therapy, LLC, & Reclaim Health, LLC
New Patient Inquiry
Seeking Chiropractic or Physical Therapy
Mees Physical Therapy, LLC. & Reclaim Health, LLC Patient Inquiry Form
Full Legal Name (as on your insurance card)
Date of Birth
Insurance Policy Company (We use this to verify your benefits)
VA, Tricare, Choice
Cash Pay ( I don't have insurance)
I understand I will receive a phone call from Mees Physical Therapy, LLC. based on the information I am providing by submitting this form. This Form cannot guarantee HIPAA Compliance. This is simply the first point of contact where we can follow up with you on scheduling an evaluation.
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service