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Date of Birth *

Full Mailing Address *

Select a PTC Location *

Insurance Provider *

Insurance Member ID *

Insurance Group # *

Name and Date of Birth of the Primary on insurance plan (if not yourself)

Name of Referring Doctor if Applicable

Questions, Comments, or Reason(s) for Visit

What body part and/or condition are we going to be treating (right, left or both)? *

Is this appointment related to a work-related injury or auto accident? *

Yes, work-related injury

Yes, auto accident

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