New Patient Registration Form

New Patient Registration Form

First Name * :
Last Name * :

Date of Birth * :
Email * :

Contact Details

Address Line 1 * :
Address Line 2 :
City * :
State * :
Zip Code *
Telephone No. * : HomeWorkCell

Referring Physician

Physician who referred you Physical Therapy :

Reason for visit* :

(e.g. Back pain, knee pain, etc…)

Appointment Request

When do you want to start?*
What days can you come?
MondayTuesdayWednesdayThursdayFridaySaturday
What time will work the best for you?
First Choice Second Choice Third Choice

Insurance Details

Insurance Carrier *
Insurance ID * :
Please specify following details:

Your Auto Insurance CompanyPolicy #Claim #Date of AccidentYour Attorney's Name
(if you have filed a petition)Your Attorney’s Tel.
Please specify following details:

Your EmployerEmployer’s Tel. Your Workers Comp. CarrierWorkers Comp. Carrier Tel.Policy #Claim #Date of Injury/Incident
Please specify.

Your Insurance CompanyInsurance Company Tel.Insurance ID

Few other details

How did you hear about us*
Please provide name
Please provide Physician's name
Please provide name of DayCare
Social website :
Please specify.

Contact info

Healing HandZ Physical Therapy
161 Lincoln Hwy. (NJ-27), Unit-A, Edison, NJ 08820

(732) 902 2700 i...@healinghandz.com

Hours of Operations

M,Tu,W       9:00 am – 2:30 pm
M,Tu,W       4:30 pm – 7:30 pm
Th,F             9:00 am – 4:30 pm
Sat               9:00 am – 1:00 pm
Sun              Closed