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Pre-Authorization Form

*First Name:

*Last:

*Address:

*City:

*State:

*Zip:

*Phone:

*Email:

*under 18?

Yes

No

if you answered yes, a parent or guardian needs to attend your appointment.

*Nature of injury & Name of Referring Provider:

*Employer:

*Referred by:

*Insurance Company:

*Phone:

Group Number:

* What services are you interested in? Mark all that apply.
	Physical Therapy		Nutrition Counseling
	Metabolic Testing		Weight Loss
	Performance Evaluations		Work Conditioning
	Golf Conditioning

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Physical Therapy | Sports Therapy | Rehabilitation Services | Orthotics | Occupational Therapy

Sports Reaction Center — Physical Therapy for Active People in Bellevue, WA
1750 112th Ave NE Suite D-154, Bellevue, Washington 98004 (425) 643-9778
Billing and Insurance Contact Numbers: (206) 542-7118 or (888) 637-0702

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Last Updated : 7/29/2010