We want your first visit a very convenient and memorable as possible. Please choose and fill out the right form and submit it to us. We also have a printable forms that you can take with you on your first visit.

      Dupont Physical Therapy strongly suggest that you read our Privacy Policy before submitting all your information to us. 

[ONLINE REGISTRATION INTAKE FORM]

Fill out this form for your online registration and submit it to us as soon as possible. All your personal information will be keep private and secured.

[ONLINE REFERRAL & PRE-CERTIFICATION FORM]

     Fill out this form for your appointment or your doctor's referral information and submit. All your personal information will be keep private and secured.

[PRINTABLE PATIENT REGISTRATION INTAKE FORM]

      Print and complete each line item. You are required to bring this form with you on your first visit if you choose not to register online.

[PRINTABLE AUTHORIZATION & ASSIGNMENT OR BENEFIT FORM]

        Print and complete each line item. You can bring this form on your first visit to determine your eligibility.

       Just a reminder what kind of form you need to bring on your first visit.

	A completed patient registration intake form if you choose not to register online.
	A completed authorization & assignment of benefit form.

[ACCEPTING PAYMENTS]

If you have any question or needed some help, you can contact us direct at (260)497-0838 our customer service representative will be glad to help you.