New Client Intake Form
Thank you for filling out this entire page and sending it to us before your first P.T. appointment.

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.

Name *
Phone *
Health insurance phone number
Health insurance phone number
Emergency contact's name *
Emergency contact's name
Emergency contact's phone *
Emergency contact's phone
What treatments have you tried for your symptoms? *
Any other symptoms? *
Other medical conditions? *
Do you use any of the following?