New Patient Intake — Vector Physical Therapy

Let's get started

Your basic contact information

First Name *

Last Name *

Date of Birth *

Mobile Phone *

We'll text appointment confirmations to this number

Email Address *

City *

Coverage & referral

How are you paying, and who sent you?

Payment Type *

💳

Cash Pay

No insurance needed

📋

Insurance

Subject to approval

Insurance Provider *

Member ID *

Group Number

Policy Holder Name

Referring Provider

Leave blank if self-referred

Referral Diagnosis / ICD-10 Code

Your doctor's office can provide this

Tell us about you

What brings you to Vector PT?

Primary Concern *

Describe your symptoms or goals *

How long have you had this issue?

HIPAA Notice & Consent

Vector Physical Therapy, PLLC is committed to protecting your health information. Under the Health Insurance Portability and Accountability Act (HIPAA), you have rights regarding your protected health information (PHI).

How we use your information: Your PHI may be used for treatment, payment, and healthcare operations. We may share your information with referring physicians, insurance carriers, and other treating providers involved in your care.

Your rights include: The right to access your records, request corrections, receive an accounting of disclosures, and request restrictions on certain uses of your information.

Security: We maintain physical, electronic, and procedural safeguards to protect your PHI. Your information is never sold to third parties.

By checking below, you acknowledge receipt of our Notice of Privacy Practices and consent to the use and disclosure of your protected health information for treatment, payment, and healthcare operations as described above.

I have read and agree to the HIPAA Notice of Privacy Practices *

✓

You're all set

Thanks — Mills will receive your intake and reach out within one business day to confirm your appointment.

Ready to pick a time? View available appointments below.

View Open Appointments

Jane App scheduling link coming soon