MOUNTAIN VIEW PHYSICAL THERAPY 3$7,(17 '$7$ 6+((7 )LUVW 0 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields, including your first name, last name, date of birth, and gender.
3. Fill in your physical and mailing addresses along with your phone numbers. Indicate the best time to call you.
4. Respond to the text message consent questions by selecting 'Yes' or 'No' for appointment reminders and marketing materials.
5. Provide details about your referring physician, date of injury, and any previous therapy services received in the last 60 days.
6. Complete the employment status section by indicating your current job situation and employer information if applicable.
7. Fill out insurance information accurately, ensuring all policy holder details are correct for billing purposes.
8. Review all sections carefully before submitting to ensure accuracy and completeness.

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