Summary

Contact Information

Location for Visit

Date of Birth

Insurance

Are you booking on behalf of yourself or another patient?

I’m booking on behalf of myself

I’m booking on behalf of another patient

Next

Let’s collect your information first.

First Name

Last Name

Email

Phone Number

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What is your relationship with the patient?

Select an option Family member Friend Professional caregiver Healthcare professional Other Select an option

Please specify

Next

Good news! We have great therapists in the region.

What's the best way to contact you?

First Name

Last Name

Phone Number

Email

Next

We recommend providing a mobile phone number for text reminder.

Would you like to add one?

Mobile Phone Number

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I don't have a mobile phone

Where would you like to see your therapist, ?

Street Address

Apt/Ste Number

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What is your date of birth, ?

Date Of Birth

Next

Are you currently receiving home health services or being treated by an in-home nurse?

No

Yes

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Home Health Discharge Information

Unfortunately, Luna does not currently support physical therapy for patients that are actively receiving home health services or being treated by an in-home nurse.

If you would like to be contacted once discharged from home health, please provide us the date of your discharge and we’ll do our best to get back to you.

Home Health Discharge Date

Submit

What is the affected body part for which you are seeking treatment?

Select an option Ankle/Foot Hip Hip - Joint Replacement Knee Knee - Joint Replacement Lower Back Neck Pelvis Shoulder/Arm Upper Back Other Select an injury

Please specify

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Would you like to use insurance to cover your visit?

Yes

No

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Who is your insurance provider, ?

Insurance Provider

We’ll confirm that you’re covered prior to your first session.

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Sounds good, .

We charge $125 for each visit. For security purposes, we’ll collect your credit card information by phone before your first session. You won’t be charged until after your session.

Next

You’re almost done, .

We need to do a short phone call with you to finalize your physical therapy appointment.

Call me now to finalize Schedule a callback to finalize