Demographic Information
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Name (first and last) *
Legal Name (if different from above)
*For Insurance Purposes Only*
Date of Birth (mm/dd/yyyy) *
My pronouns are : (she/her, he/him, they/them, etc) *
For insurance purposes, what is your sex assigned at birth?
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For insurance purposes, your gender identity is: *
My sexual orientation is: *
Email Address *
Phone Number *
Mailing Address (street, state and zip code) *
I give permission to the Fosnight Center for Sexual Health to leave messages on my voicemail. *
Preferred Method of Contact *
Name of Insurance Provider *
Insurance Policy Number/Subscriber ID *
Relationship Status *
Employment *
Primary Care Provider *
Referring Care Provider *
Preferred Pharmacy *
Preferred Pharmacy Phone Number
Preferred Pharmacy Address
Emergency Contact *
Emergency Contact Relationship
Emergency Contact Phone Number
How did you hear about the Fosnight Center? *
What type of appointment are you here for today? (click all that apply) *
Required
Have you received rehabilitation services for this or another condition from any of the following this calendar year? (check all that apply) *
Required
Are you currently seeing another physical therapist, occupational therapist, or chiropractor for any concerns?  *
*If you answered yes, insurance will not cover visits with one of our physical therapists in the same day as one of the above mentioned providers. Visits with our therapist will be required to be scheduled on a separate day.
My sex assigned at birth is: (this will be used to determine the most accurate medical history) *
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