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Request for Physical Therapy Cost Estimate

Please complete and submit the form below if you would like a cost estimate for physical therapy services. We will call you within 2 business days and work with you to determine an approximate cost. Please have the following additional information available when we call:

      • Insurance Contractor or ID Number
      • Insurance Group Number
      • Insurance Phone Number (if not provided below)

Note: Estimates will be provided if your residence is within a reasonable proximity to our offices such that you could attend physical therapy at Back in Motion should you desire to do so.

Name:

Age Range: Phone Number:

Where is the issue troublesome? (check all that apply)
Back
Neck
Arm (s)
 Knee (s)
Buttocks
Legs
 Other
(Please describe)


Type of Insurance:

Insurance Co. Phone Number: (Optional)



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