New Patient Intake

Pick PT wants to assure that your first appointment has no unexpected delays. Please arrive 15 minutes before your first scheduled appointment. Please fill out the online form below and download the medical intake and consent forms and fill them out. You can bring them in or e-mail them for your first appointment. This will save time when you arrive at our office.

Patient Medical Intake Form Patient Info/Consent Form

Patient Information

Name(Required)

Prefix First Middle Last

Preferred Name

First Last

Gender(Required)

Male

Female

Birth Date(Required)

Student Status(Required)

Marital Status(Required)

Contact Information

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Preferred Phone Number(Required)

Home phone

Mobile phone

Both

Home Phone(Required)

Mobile Phone(Required)

Preferred Contact Method(Required)

Emergency Contact

Name(Required)

First Last

Relationship(Required)

Contact's Phone Number(Required)

Employer Information

Employer's Name

First Last

(208) 534-7001
Fax: 208-534-7002
Email: patientservices@pickpt.com

2277 E Lincoln Rd
Idaho Falls, ID 83401
Hours: Mon-Fri 8am-6:30pm

921 S Utah Ave
Idaho Falls, ID 83401
Hours: Mon, Wed, & Fri 7am-6pm
Tues & Thurs 8am-12pm

3155 Channing Way D
Idaho Falls, ID 83404
Hours: Mon & Weds 7am-7pm
Tues & Thurs 8am-12pm
Fri 7am-6pm