New Client Intake Form
Thank you for filling out this entire page and submitting it to us. We will review your submission and contact you to schedule. On average, we will be able to accommodate new client evaluations approximately one month from now.

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. You are welcome to print this form and submit them via mail if you prefer.  

Name *
Name
Phone *
Phone
Provider phone number on back of your insurance card
Provider phone number on back of your insurance card
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?