Pediatric patients:


*Pelvic  or Orthopedic  Medical History


*If participating in telehealth services, this credit card form is required


*Add your credit card on file to be put on auto-charge!

​New Patient Forms

Female Patients:


*Pelvic  or  Orthopedic  Medical History


*If participating in telehealth services,

this credit card form is required.


*Add your credit card on file to be put on auto-charge!

Inside Natural Balance Wellness Center: 719 Lake Avenue, Peoria, Il 61614


Phone:309-839-8631        Fax: 855-579-3536        Text: 309-253-1306        Billing: 309-256-8312        lisenbypt@gmail.com

Please fill out the forms included in the "Pelvic Medical History" link below if you are being seen for Pelvic Health conditions such as Incontinence, Post-partum conditions, Pelvic Pain, Pain with Intercourse, or Prolapse. 


Please fill out the forms included in the "Orthopedic Medical History" link below if you are being seen for Orthopedic conditions such as Back or Neck Pain, Dizziness and Balance Disorders, Pregnancy, or Joint or Muscle Pain.


Please fill out telehealth credit card form for Telehealth services if you are planning to be seen via Telehealth.


Lisenby Physical Therapy for All does not take onsite payments via check, card, or cash. 

We want our therapists to be able to focus on your care and not use vital treatment time to complete these types of tasks.  Please fill out the Credit Card authorization form and we will auto-charge your card for copays and self-pay rate at time of service.  For those with deductibles or co-insurance your card will be charged for balances due upon receipt of your verification of benefits after we recieve it back from your insurance company. Our receptionist and billing staff, at our main location, will be happy to assist you with any questions or needs you may have.

​We do apologize for any inconvenience this may cause but are confident this gives our therapists more time to focus on your care! 


Please print and bring all forms with you to your appointment, or you can email a completed copy to lisenbypt@gmail.com. If you are unable to complete these forms beforehand, please come 15 minutes early to complete them in office, before your appointment. Failure to do so, may result in an incomplete initial exam and delay your treatment progression.


Also, please bring your photo ID and insurance card(s) that we will be billing to your appointment.

Lisenby Physical Therapy for All

Male Patients:


*​Pelvic  or  Orthopedic Medical History


​*If participating in telehealth services,

this credit card form is required


​​*Add your credit card on file to be put on auto-charge!