Euro-Peds has three intensive PT programs to help children reach their full potential. Complete our no-obligation, online application to learn what may work best. Our director reviews every application to ensure patients are appropriate candidates for the programs. Learn more here. A paper application is available here.

* = Required field

Date of Application:
Child's First Name:*
Last Name:
Date of Birth:*	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976
SS #:
Sex:*	MaleFemale
Parent/Guardian:*
Address:*
City:*
Country:*	Country United States Canada
State:*	State/Province US: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY CANADA: AB BC MB NB NL NT NS NU ON PE QC SK YT
Zip:*
Primary Phone: *
Secondary:
Other Phone:
Fax:
E-mail:*

	Emergency Contact Names/Numbers:*
1.	What Are The Child's Diagnoses:*:
2.	Child's Height:* inches      Child's Weight:* lbs
3.	Current Medications (Also include reason for taking):*
4.	Please Provide Phone Numbers to Specialists Who Treat Your Child:
5.	Past Medical History:*

Please Indicate If Your Child Has a History of the Following. If Yes, please describe:*
YesNo		Seizures (How often/date of last occurrence?):
YesNo		Scoliosis (What degree of scoliosis?):
YesNo		Hip subluxation (What %?):
YesNo		Fractures:
YesNo		Vision/Hearing Problems:
YesNo		Ventriculoperitoneal Shunt(Hydrocephalus):
YesNo		Gastrointestinal Tube (G-Tube):
YesNo		Tracheostomy Tube (Trach):
YesNo		Botox/Phenol Injections:
YesNo		Heart, Lung, Kidney, Diabetes, etc.:

6.	Surgical History (muscle or tendon lengthening/releases, selective dorsal rhizotomy, baclofen pump, spinal fusion/rods, osteotomy, reconstructive joint surgeries, etc):*
7.	Has your child received other physical therapy services this policy year? (If yes, how often and where?):*
8.	Past & Current Medical Equipment (braces, walker, crutches, wheelchair, etc):*
9.	Child's Abilities (rolling, sitting, crawling, walking, etc):*
10.	How Do You Communicate With Your Child/How Does He Or She Communicate With You?:
11.	Is Your Child Able to Follow Simple Commands?:*
12.	Have you ever been told that your child is not a candidate for therapy at Euro-Peds? (If yes, please explain):*
13.	Has your child received their immunizations? (If no, please explain):*
14.	How did you hear about Euro-Peds?*      -- Select One -- Physician Therapist Internet Expo / Conference Patient Referral News Story Support Group Other
	Further detail: (physicians name, website address, etc.)*

15.	Referring Physician's Information:
	Name:
	Address:
	Phone #:		Fax #:
	License #:		Exp Date:
	NPI #:

	Insurance Information Primary Insurance Company
	Company Name:
	Subscriber:		Subscriber's DOB:
	Contract #:		Group #:
	Employer:		Provider Phone #:
	Secondary Insurance Company
	Company Name:
	Subscriber:		Subscriber's DOB:
	Contract #:		Group #:
	Employer:		Provider Phone #:
	Submit