New Patient Registration

Seamless Onboarding for Your Therapy Journey

New Patient Registration Forms

Welcome to AR Physical Therapy! We aim to make your onboarding process as smooth and straightforward as possible. Our new patient registration form is designed to gather essential information, allowing us to tailor your care from day one. Simply complete the form below, and our team will be ready to support you every step of the way, ensuring a personalized and effective therapy experience.

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Required information marked with *.

01. Patient Information

First Name*

Middle Name

Last Name*

Preferred Name

Gender *

Preferred Pronouns

Birthday ( MM / DD / YYYY ) *MONTH

DAY

YEAR

Student Type *

02. Address

Building Type

Street Address*

Other Designation

City *

Postal Code *

State *

Country *

03. Contact

Email *

Primary Phone * (Mobile)

Secondary Phone (Home)

Preferred Contact Method

04. Emergency Contact

First Name *

Middle Name

Last Name *

Relationship *

Contact Phone Number *

04. Employment Information

Employer's Name

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New Patient Registration