Please fill out this form for clients that are younger than 1 year old. Thank you for filling out this registration form. I will review it and contact you to schedule via email. Alternatively, you may print this form and submit it by mail.

Infant's Name

First Name

Last Name

Infant's Date of Birth

YYYY

Infant's Gender

Parent or Caregiver's Name

First Name

Last Name

Parent or Caregiver's Email

Parent or Caregiver's Phone

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Parent or Caregiver's Name

First Name

Last Name

Describe baby's family, home, schedule

Infant's health care providers:

Current feeding

Infant's Medical History

Please list your reason for seeking care for this child:

Any additional information you would like to share?

Shine PT does not bill any insurance company directly. Please note that if you are interested in reimbursement or credit for your payments from your insurance, please use the link below to find out if they require before answering the following:

We strongly recommend that you call your insurance company prior to your first visit to learn about your coverage with us. We are happy to help with any questions after you have spoken with your insurance to fill out this form.

By initiating communication via email or internet contact form and/or responding to an email sent by Shine Integrative Physical Therapy or any of Shine's employees, you are giving consent for initial and continuing communications through these means, while acknowledging potential risks of non-encrypted email communication.

Infant Intake Form

Shine Integrative Physical Therapy