Kindly fill out the insurance information below so we verify your benefits and get back to you within 48 hours. From there, you can decide if you like to move forward with the first visit.

Which service do you need? *

Pick a date that works best for you *

Indicate your ideal time *

Where does it hurt? *

What does it STOP you from doing? *

What concerns you most? *

First Name *

Last Name *

Phone *

Date of birth *

Email Address *

File Upload

Upload your insurance card and driver’s license (front and back) to skip completing the information below. You may take a photo with your phone and upload it here (Optional)

Name of your insurance

Member ID of your insurance

Provider Number (Located in the back of the card) or sometimes it may be called benefits/eligibility line

Are you the policy holder? If yes, put yes. If no, please put in the full name & date of birth of the policy holder.

Address listed with your insurance

I agree to receive calls and text messages from Empowerment Physical Therapy, including messages sent using automated technology, prerecorded voice, or AI-assisted calling systems, at the phone number I provided. These messages may include appointment reminders, follow-ups, service updates, and marketing communications where allowed by law. Consent is not a condition of purchase. I understand I can opt out at any time.

Just making sure you’re human!