TC serves PA and NJ

Patient Intake Form

PRIVACY STATEMENT

A picture of Patient Intake Form with Therapy Choice in Pennsylvania

Fill the Form

Please note that no personal information from this form will be stored on our website database. All information is securely directed and saved in our clinic’s Electronic Medical Record (EMR) system where all data is encrypted. The patient information will only be used by the clinic and will not be passed on to any third party.