Perfect Motion Sports Therapy

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What kind of care is being sought?

Physical Therapy Personal Training Baseball Pitching Training Shockwave Neuropathy Program Unsure, I just know I need help

Administrative

Inquiry reason

How Did You Hear About Us?

Facebook Ad? Social Media Follower? Friend? Doctor? Past Patient? Please let us know who we can thank.

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Billing & Payment

Payment method

We are a Concierge Level Provider and do not directly contract with insurance companies. We do, however, give you all the documentation to get reimbursed or count against your deductible. We give actual cash discounts. What method of payment might you use: credit card, CareCredit, HSA/FSA, Check, or Cash? (this answer does not lock you in to a specific method)

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Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.