Please fill out the form below to the best of your ability and complete all fields.
Please fill out the form below prior to coming to your appointment:
How did you hear about us?
Please enter your Age:
Please enter your Date Of Birth:
Please enter your Primary Diagnosis
Name of the Referring Physician
What are your personal Goals for therapy?
What is your current pain?
What is your current caregiver support?
Affected side (if applicable):
Date of Injury (if applicable):
Please explain your past Medical History:
How are you currently getting around (Do you use a walker, wheelchair,etc):
What services are you interested in?
Physical TherapyOccupational Therapy
Aquatic TherapyFitness Therapy
Please select a preferred Location:WestminsterTimonium
How would you prefer to be contacted: ---PhoneEmail
Best time of day: ---9:00am10:00am11:00am12:00pm1:00pm2:00pm3:00pm4:00pm5:00pm6:00pm
Please pick your ideal day for an: MondayTuesdayWednesdayThursdayFriday* Hold Ctrl to select multiple
7 Tuc Road - Suite A
Westminster, MD 21157
Phone Number: 410-871-2494
Fax Number: 410-861-5303
61 East Padonia Road - Suite E
Timonium, MD 21093
Phone Number: 410-415-1992
Fax Number: 410-774-0488
© 2017 Therafit Rehab - Physical Therapy. TheraFit Enterprises, Inc.