Mees Physical Therapy, LLC, & Reclaim Health, LLC
New Patient Inquiry
Email address *
Seeking Chiropractic or Physical Therapy *
Mees Physical Therapy, LLC. & Reclaim Health, LLC Patient Inquiry Form
Full Legal Name (as on your insurance card) *
Your answer
Date of Birth *
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Address *
Your answer
Phone Number *
Your answer
Insurance Policy Company (We use this to verify your benefits) *
Policy Number *
Your answer
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.
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