New Patient Forms
  • Covington253.639.2266
  • Maple Valley425.433.0123
  • Enumclaw360.825.7411

Healthy Foundations/POP

Thank you for your interest in our 16-week Healthy Foundations/POP program. All of this information will be kept confidential and will be used to provide an accurate cost estimate depending on your insurance plan(s). Please fill out the form below and we will get back to you as soon as we can with more information on how to get started.

 
How did you hear about the program? *
Name *
Primary Phone Number *
Secondary Phone Number *
E-mail *
Best way to reach you *
Date of Birth *
Preferred location *
Primary Insurance Carrier *
Examples: Regence, Premera, Medicare
Primary Insurance ID # *
Primary Insurance Group # *
Secondary Insurance Carrier *
If applicable
Secondary Insurance ID # *
If applicable
Secondary Insurance Group # *
If applicable
Referring Physician *
Have you been diagnosed with diabetes? *
Are you having joint replacement surgery? *
If yes, knee or hip surgery? *
Scheduled Surgery Date *
If applicable
Sign up for Pinnacle's monthly newsletter (Nutrition, Fitness & Wellness info)! *
Questions/Notes *
 

It is important to know that physical therapy can be provided only by qualified physical therapists or by physical therapist assistants working under the supervision of a physical therapist.

Call Pinnacle at 253.639.2266 to learn how we can help you.