Request An Appointment
Please complete ALL information requested below and one of our associates will promptly respond to your request.
Client Name :   Age :  
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?
Message/Comments:
                                  
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
  • Print  
  • Patient Intake Health Questionnaire
  • Print  
           
             NOTIFICATION (no need to print this)    
  • HIPAA
  • Print  
  • Important Company Policies for a Successful Relationship
  • Print  
           
    Complete this form DURING the first appointment :    
  • Theramax Rehab Patient Agreement
  • Print  
     
     
    Excited for your first appointment?
    Don`t forget the 5 Do`s! Please click here.
     
    Confidentiality Notice:
    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