New Patient Intake Form

If you're already a patient, please fill out the appointment request form for your preferred location

Patient Information

Diagnosis/Injury Description

Medical History

Medications List

Please list all medications, including all prescriptions, over the counter medications, herbals, minerals, vitamins, and dietary supplements.

Employment Information

Insurance

Automatic Appointment Reminders

Complete this form and sign below to give Agape Physical Therapy your permission to provide automatic appointment reminder service by cellular text message or automated phone call. Text messaging rates may apply. We cannot activate your text message appointment reminders without knowing your cellular carrier. If your carrier is not listed, we will be unable to activate text message alerts for you.

HIPAA Acknowledgement of Receipt of Notice

I hereby acknowledge that I have been informed of the Agape Physical Therapy HIPAA Notice of Patient Information Privacy Practices. I give Agape Physical Therapy permission to leave voicemails regarding appointments and / or care at previously listed and below listed phone numbers. I give Agape Physical Therapy permission to discuss my information regarding Physical Therapy with the following people.