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Therapy Evaluation

This package includes a comprehensive evaluation with a licensed therapist, all-inclusive treatment, and the determination of a care plan. If you have a referral from a practice other than EmergeOrtho, PA please bring it to your visit.

*This does not include dry needling and/or custom bracing

$125.00

Patient Name

DOB (mm/dd/yyyy)

Direct Pay Service

I acknowledge this direct pay service will not be filed with my insurance and cannot be filed at a later date.

Refund

I will not be refunded if services are rendered. However, I acknowledge I will be refunded if my provider does not agree with the plan of care and services are not rendered.

Business Day Delay

If payment made after hours, on the weekend or holiday, your payment may not be posted to your account until the next business day. Please show your emailed receipt at your upcoming appointment.