New Patient Forms
Please fill out these forms prior to your appointment. 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.
Please fill out one of the secure forms below that best fits your reason for physical therapy care.
In the Glen Professional Plaza: 5009 North Executive Drive, Suite B, Peoria, IL 61614
Phone:309-839-8631 Fax: 855-579-3536 Text: 309-253-1306 Billing: 309-256-8312 firstname.lastname@example.org
for Pelvic Health conditions such as Incontinence, Post-partum conditions, Pelvic Pain, Pain with Intercourse, or Prolapse.
for Orthopedic conditions such as Back or Neck Pain, Dizziness and Balance Disorders, Pregnancy, or Joint or Muscle Pain.
for all Pediatric health conditions such as Bed Wetting, General Orthopedic Pain/Strains, Constipation, Bladder Conditions, Postural Abnormalities, Sports Injuries.