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Give us a call, send an email, or simply fill out the form below that best suits your contact needs. Same Day and Next Day Appointments available! We guarantee to reach out to you within 24 hours of receiving your inquiry!

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Please Fill Out The Form Below That Best Suits Your Needs

NEW PATIENTS NEVER SEEN AT OUR OFFICE

Name*

Phone*

Email Address*

Person Making Appointment*

Insurance Type*

If you've chosen "other" for insurance type, indicate the insured's insurance type

Start Treatment Date*

Do you have a referral for PT?*

Referring Dr. or PCP

Additional Information

Please do not forget to address any questions or concerns you may have. Our dedicated Staff will reach out to you within 24 hours of form submission.

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Thank you for your interest in receiving services at Frederick Physical Therapy, Inc. Congratulations! You've already started your path to living a pain-free, and more fulfilling life. Stay on the look out for a Staff member of ours to contact you within 24 hours.

MEDICAL NOTES REQUEST

I WAS ONCE A PATIENT AT YOUR OFFICE, I NEED TO SCHEDULE PT AGAIN

Patient's First and Last Name*

Patient's DOB*

Email Address*

Telephone Number*

Your Relation to Patient*

HIPPA Privacy Policy Requirement

Preferred Method of Communication*

Patient's Insurance*

Type patient insurance carrier and plan name if applicable. If the insured name is different than the insurance policy holder, under the age of 21, or has a guarantor, please include policy holder's first name, last name, and DOB.

Target PT Start Date*

PT/PTA worked with in past at FPT*

Therapist Preference for Upcoming PT

Please leave blank if you do not have a preference.

Additional Comments

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Address

196 Thomas Johnson Drive, Suite 225, Frederick, MD 21702

We are located in the Thomas Johnson Medical Center

Contact

Tel: (301)631-5300

Fax: (301)631-5301

Hours

M-Th 7:30am-6:10pm

Fri 7:30am-3:10pm

Sat 8:00 am-12:00pm

Sun Closed

Email: [email protected]