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:* MM/DD/YYYY  
SS #:
Sex:*  
Parent/Guardian:* 
Address:* 
City:*  
Country:*
State:*  
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:*
  Seizures (How often/date of last occurrence?):
  Scoliosis (What degree of scoliosis?):
  Hip subluxation (What %?):
  Fractures:
  Vision/Hearing Problems:
  Ventriculoperitoneal Shunt(Hydrocephalus):
  Gastrointestinal Tube (G-Tube):
  Tracheostomy Tube (Trach):
  Botox/Phenol Injections:
  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?*       
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