Thank you for filling out this entire page and submitting it to us. We will review your submission and contact you to schedule. 

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 *
Phone *
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?

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.