Appointment Request Patient's Legal Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Does the patient go by their legal first name?(Required) Yes No What name does the patient go by?(Required) Patient's Date of Birth(Required) Month Day Year Phone Number(Required)Email Address(Required) Health Insurance Plan(Required) Policy Number (MEMBER ID, ENROLLEE ID)(Required)INCLUDE LETTERS AND NUMBERS Is the patient the primary insured?(Required) YES NO Primary Insured's Name(Required) Primary Insured's Date of Birth(Required) Month Day Year What is the patient's relationship to the primary insured?(Required)SELECT FROM THE DROP DOWN MENUSPOUSECHILDLIFE PARTNEREMPLOYEEOTHER/UNKNOWNWhat Are We Seeing The Patient For?(Required)BRIEF DESCRIPTION OF THE BODY AREA(S) OR PROBLEM(S) TO BE TREATEDIs this problem related to an accident/incident where a third party is liable?(Required) NO YES Accident / Incident Date(Required) MM slash DD slash YYYY Which third party is liable?(Required)MOTOR VEHICLE ACCIDENTWORK RELATED ACCIDENT (WORK COMP CLAIM)OTHER ACCIDENT WHERE THIRD PARTY IS LIABLEDo you have a referral from your doctor for this Workers Compensation claim? Yes No Please ask your doctor to fax the referral to us at 208-344-0759. We cannot treat a Workers Compensation patient without receiving a referral from your doctor first. Additionally, we may need to obtain prior authorization depending on your Workers Compensation policy.Claim Number(Required) Adjuster / Case Manager Name(Required) First Last List your doctor(s)?(Required)How did you hear about us?(Required) Preferred days and times(Required)Comments / QuestionsContact for scheduling(Required)The next step is to get you scheduled, please select the best ways to contact you. Emails come from front-desk@thriveptpilates.com, phone calls come from 208-344-0737, and text messages come from 208-992-5811. Please create a contact for Thrive Physical Therapy with the above information so that we can connect without delay. Email Phone Text Select All Δ TweetSharePinShare
