New Patients - ProImpact

Here at ProImpact we are ready to get started serving you and your rehabilitation needs. Before we get going, we need information on the patient. Patient, medical and insurance information needs to be gathered so we can serve and treat you in the best way possible.

You will find a patient form below that you can fill out online. If you would rather download, print, and fill out the form via PDF download, you can do that and fax them to our office (334-239-8126), email them ([email protected]) or bring them with you to your appointment.

New Patient Form

Patient Information

Last Name

First Name

Middle Name

Referring Physician

Today's Date

Prefix

Mrs

Miss

Sex

Marital Status

Social Security Number

D.O.B.

(MM/DD/YEAR

Age

You will receive your statement at this email address!

Patient Cell Phone Number

If patient is a student, please provide the parent's number.

Cell Phone Number Contact

Mom

Dad

Other

If this is not the patients cell phone number, please provide details

Name of "Other if applicable

Home Phone Number

Street Address

City

State

Postal Code

Country

Occupation

Employer

Employer Phone Number

If you are human, leave this field blank.

Welcome New Patients

Patient Information