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Appointment Type
*
Initial Evaluation
Free Screen in Clinic (15 mins.)
Free Call (15 mins.)
First Name
*
Last Name
*
Email
*
Phone
*
Nearest TheraFit Rehab
*
Selection the location nearest to you.
Baltimore, MD/Cold Spring
Towson, MD
Westminster, MD
Woodlawn, MD
Matawan, NJ
Middletown, NJ
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What services are you interested in?
Physical Therapy
Occupational Therapy
Speech Therapy
Fitness Therapy (self-pay)
Referral Source: How did you first see or hear about TheraFit Rehab? (Helpful but not required.)
Community Expo/Festival that TheraFit Attended
Facebook Ads
Google Ads/SEO
Health Care Provider (Nurse, Other Therapy Clinic, etc.)
Insurance
I am a Past Patient
Interdisciplinary (from a TheraFit Therapist)
Mailer/Postcard
Newspaper
Physician
Social Media Post (not an Ad)
Staff Member (Family or Friend Works at TheraFit)
TheraFit Event
Walk-In
Website
Word-Of-Mouth
Workshop
Other/Unknown
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Type of Insurance (Required if you selected Initial Evaluation as appointment type; optional for others.)
Aetna
Aetna Better Health
Alterwood Health Advantage
American Specialty Health
CareFirst/BCBS HMO/PPO/POS
Cash Pay
ChampVA
Cigna
Golden Rule
Humana (out-of-network)
Johns Hopkins EHP
Johns Hopkins US Family Plan
Kaiser Permanente
Maryland Physicians Care
Medicaid
Medicaid MCO's
Medicare
Medrisk
MedStar (out-of-network auth. req.)
Meritain Health
Meritain Health (out-of-network)
Priority Partners
Qualcare by Cigna
Tricare Standard/Tricare for Life
UMR
United Healthcare (UHC)
United Healthcare Community Plan
VA Community Care Network
Other
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Primary Complaint or Other Comments:
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