This electronic portal is protected by HIPAA-compliant TLS (Transport Layer Security) encryption to safeguard your Personal Health Information (PHI). Your privacy, as well as your rehabilitation is extremely important to us.

The information gathered in this form will be securely linked to the email address you provide. It is very important that you use an email that is password protected and accessible only by you. Attestations and acceptance of the terms below will be considered valid and binding per the Uniform Electronic Transactions Act.

We do things a little different at PT Revolution. We're going to tell you what we charge and what your share of cost will be UP FRONT. Nothing ruins a successful course of rehab like a monster bill landing in your mailbox a few months after you're back in action.

In order to do this, we need to you to complete this form ASAP so we can get you in our system, verify your insurance benefits (when applicable), secure your spot on the schedule, and make sure there are no surprises.

It will take about 10-12 minutes so grab a snack, stay hydrated, get comfortable, and start typing!