Request An Appointment
Please complete ALL information requested below and one of our associates will promptly respond to your request.
Client Name :
Mobile number :
Zip Code :
Email Address :
If minor: name of the guardian?
Best Day for the first Appointment?
Best Time for the first Appointment ?
Describe what is the problem?
What is your goal for this appointment?
Kindly Input code :
Express Registration (For Adult Outpatient Rehab use only.
We value your time. Fill out the majority of your forms at home to speed up your registration process on the first visit.
NOTE: no matter what type of service you're booking, you will be required to have a valid credit card in your profile to reserve your appointment. Before you get to the checkout and payment screen, you will be prompted to enter your credit card information. You will not be charged. You can change your payment arrangement when you arrive, but only a credit card ensures we reserve your time slot and protects us from last minute cancellations.
New Patient Forms :
Patient Express Registration Form
Patient Intake Health Questionnaire
NOTIFICATION (no need to print this)
Important Company Policies for a Successful Relationship
Complete this form DURING the first appointment :
Theramax Rehab Patient Agreement
Excited for your first appointment?
Don`t forget the 5 Do`s!
Please click here.
THIS INFORMATION CONTAINED IN THIS FORM IS CONFIDENTIAL AND/OR PRIVILEGED. IF THE READER OF THIS TRANSMITTAL PAGE IS NOT THE INTENDED RECIPIENT OR A REPRESENTATIVE OF
THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY REVIEW, DISSEMINATION COPYING OF THIS FORM OR THE INFORMATION CONTAINED HEREIN IS PROHIBITED. IF YOU RECEIVED
THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY BY TELEPHONE AND DESTROY ALL COPIES OF THE ORIGINAL MESSAGE. THANK YOU
Services: Geriatric and Pediatric PT, OT, MSW, ST, Home Saftey Assessment, Assistive Device Assessment
and Recommendation, Caregiver Recommendation, Area of Coverage: Houston, Stafford, Sugar Land, Wharton, MIssouri City, Arcola, South Houston,
Dickinson, La Marque, Texas City and Galveston TX. Send patient today! PO Box 37042 Houston TX 77237 Tel # 713.244.9505
All rights reserved Theramax Therapy Services, PC © 2012