PATIENT FORMS

Gulf Coast Physical Therapy Patient Form

Fill Out Our Patient Form to Get Started

Check out our complete patient form and fill out the important details before you schedule your appointment with us. At Gulf Coast Physical Therapy, we provide various physical therapy and rehabilitation programs to help you recover from your injury or develop your overall wellness.

Patient Info:

Full-time
Part-time
Restricted Duty
Retired
Unemployed
Heart Problems
High Blood Pressure
Active Tuberculosis
Seizures
Pacemaker
Diabetes
Pregnant
Cancer
Other
NONDISCRIMINATION POLICY

As a recipient of federal financial assistance, the Gulf Coast Physical Therapy does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, or national origin, or on the basis of disability or age in admission to, participation in, or receipt of the services and benefits of any of its programs and activities or in employment therein, whether carried out by Gulf Coast Physical Therapy arranges to carry out its programs and activities.

This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 19873, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to the Acts, Title 45 Code of Federal Regulations Part 80, 84, and 91. (Other Federal Laws and Regulations provide similar protection against discrimination on grounds of sex and creed.)

In case of questions concerning this policy, or in the event of a desire to file a complaint alleging violations of the above, please contact:

Gulf Coast Physical Therapy
228-822-9066
TDD

The following is a notice of non-discrimination which was found to be acceptable as a shortened version of a provider’s adopted policy of nondiscrimination. Owing to its brevity, such a statement is more convenient to include in publications, announcements, advertisements, etc., than the complete policy.

Gulf Coast Physical Therapy does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact (Gulf Coast Physical Therapy, 228-822-9066, TDD).

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