| Discovery Call Intake

Full Name *

Phone *

How Did They Find Us? *

Email *

Patient Date of Birth *

Parent or Guardian Full Name

Parent or Guardian Date of Birth

Send Insurance Request?

Yes, send them an email/text to collect their insurance info.

If you select "Yes", they will be sent an email and text with links to a form to submit a picture of their insurance card.

Inquiry Follow-Up?

Yes, follow-up later

Yes, follow-up on a specific date

No need to follow-up later

SMS Consent *

I consent to receive marketing text messages from KRU PT and Performance Lab at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out. agree to get confirmations, reminders, and updates via SMS.

I consent to receive non-marketing text messages from KRU PT and Performance Lab about my order updates, appointment reminders etc. Message & data rates may apply.