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
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511 Jermor Lane – Suite 101
Westminster, MD 21157
61 East Padonia Road – Suite E
Timonium, MD 21093
37 Kanes Lane
Middletown, NJ 07748
© 2017 Therafit Rehab - Physical Therapy. TheraFit Enterprises, Inc.