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Boston Health and Wellness Intake Forms
Please fill out the questions below and we will get back to you within 24 hours to confirm your initial appointment! If you have any questions or would like to do this over the phone please call the office at (617) 843 - 5320
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* Indicates required question
Full Name
*
Your answer
Date of Birth
*
Your answer
Mobile Phone Number
*
Your answer
Is it okay if we text this number? One of our Doctors of Physical Therapy will reach out to you about setting up your initial appointment
*
Yes
No
How did you hear about us?
*
Google Search
Instagram
Facebook
Someone referred me
Doctor or insurance company
Other:
Email Address
*
Your answer
Full Mailing Address (Street, City, State, Zip) *PLEASE INCLUDE ALL INFORMATION*
*
Your answer
Name of insurance company
*
Choose
Aetna
Allways
Blue Cross Blue Shield
Harvard Pilgrim
Medicare
Masshealth
Tufts
Unicare
United Healthcare
other
Insurance ID #
*
Your answer
Type on Insurance
*
HMO
PPO
Other:
Please briefly describe your symptoms
Your answer
Do you have a referral from a physician or doctor?
*
Yes
No
Please list your Primary Care Physician and their phone number
*
Your answer
Please send a picture of front and back of your insurance card to our insurance coordinator. This is very important! If we do not receive this before your initial appointment we can not submit to insurance for coverage! Email:
bostonhealthwellness@gmail.com
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