Please click here
to fill out our appointment request form for current patients.
Please list all medications, including all prescriptions, over the counter medications, herbals, minerals, vitamins, and dietary supplements
Please provide your personal insurance information if you would like as back up to your Motor Vehicle insurance.
Automatic Appointment Reminders
Complete this form and sign below to give Agape Physical Therapy your permission to provide automatic appointment reminder service by either email or cellular text message.
I recognize that 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.