Central Scheduling (260)209-2464 · ☏ Business Office (260) 432-4700 comments@indianapt.com

Pre-Registration Form

Fill out the pre-registration form below prior to your appointment or download the complete registration form PDF by clicking here Pre-Registration Form PDF to fill out, and bring in with you to your appointment.

    PATIENT INFORMATION
    Patient's Name: First:
    Middle Initial:
    Last Name:

    Street Address:
    City:
    State:
    Zip:

    Home Phone:
    Cell Phone:

    Your Email (required)

    Date of Birth (mm/dd/yyyy):