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Filling Out a Medical Form

New Patient Form

Please fill out the following form prior to your appointment. Call us with any questions, we look forward to seeing you!

First Name

Email Address

Last Name

Date of Birth

Address

Phone

Is your current problem due to an accident?

Workers Comp

Auto

School

No, my injury was not caused by an accident

If YES, enter billing claim # and billing information here:

Student Athlete Injury?

Date of Injury

Primary Care Physician

Referring Physician

Did referring doctor mention us?

Yes

No

If not how did you hear about us?

Primary Insurance

Secondary Insurance

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Scheduling an appointment is easy! We're Not Far from Home

We offer convenient appointments at any of our three clinics. Call today for an immediate appointment.

Old Forge Office

Old Forge Office

501 South Main Street
Old Forge, PA 18518
(570) 457-4099

arch clinic outside.jpg

ARCHBALD Office

1 Highland Blvd Suite 108

Archbald, PA 18403
(570) 383-8841

Hamlin Office

Hamlin Office

501 PA-590
Hamlin, PA 18427
(570) 689-7786

Physical-Therapy-Associates-NEPA_clipped

No matter what your injury is a result of, you can be sure that Physical Therapy Associates of NEPA will provide you with the skilled, one-on-one care for the results you need. We don’t simply treat your injury or condition. Our Physical Therapists are committed to providing quality care in a comfortable, friendly setting. We are dedicated to making your experience as pleasant as possible.

Fast, easy scheduling
Evening appointments available
Private treatment rooms
Most insurances accepted
Insurance & benefit guidance available
Medicare is welcome
Handicapped-accessible
AMEX, MC, Visa & Discover are accepted

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