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Intake Form

If you are scheduled with Wheels on the Bus' services, please fill out the intake form below.

You can alternatively download the PDF and email to kyle@wheelspediatrictherapy.com

 

Thank you!

Client Name*

Address*

City*

State*

Zip Code*

Phone Number*

Gender*

Date of Birth*​

Patient/Guardian Name(s)*

Client Doctor (Full Name)*

Doctor's Full Address*

Doctor's Fax Number*

Diagnosis*

Insured Information (Name)*

Address*

Phone Number*

Gender*

DOB*

Employer*

Employer Phone*

Insurance Company Information*

Effective Date*

Plan (HMO/PPO/Other)*

Billing Address*

Insurance Company Phone*

ID #*

Group #*

Authorized Signature*

Medical Release*

Cancellation Policy*

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