New Patient Intake

Pick PT wants to assure that your first appointment has no unexpected delays. Please arrive 15 minutes before your first scheduled appointment. Please fill out the online form below and download the medical intake and consent forms and fill them out. You can bring them in or e-mail them for your first appointment. This will save time when you arrive at our office.

Patient Medical Intake Form Patient Info/Consent Form

Patient Information

Name(Required)

Prefix First Middle Last

Preferred Name

First Last

Gender(Required)

Male

Female

Birth Date(Required)

Student Status(Required)

Marital Status(Required)

Contact Information

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Preferred Phone Number(Required)

Home phone

Mobile phone

Both

Home Phone(Required)

Mobile Phone(Required)

Preferred Contact Method(Required)

Emergency Contact

Name(Required)

First Last

Relationship(Required)

Contact's Phone Number(Required)

Employer Information

Employer's Name

First Last

Fax: (208)534-7002
Email: patientservices@pickpt.com

Rexburg

160 W 2nd S #1
Rexburg, ID 83440

(208)534-7001

Fax: (208)534-7002

Mon & Wed 7am-7pm
Tues & Thurs 8am-12pm
Friday 7am-6pm

Rigby

711 Rigby Lake Dr Suite 600
Rigby, ID 83442

(208)754-1210

Fax: (208)754-1220

Mon, Wed, & Fri 7am-7pm
Tues & Thurs 8am-12pm

Idaho Falls

Idaho Falls North

2277 E Lincoln Rd
Idaho Falls, ID 83401

(208) 701-1800

Fax: (208)534-7002

Mon, Wed, & Fri 7am-7pm
Tues & Thurs 8am-12pm

Idaho Falls West

921 S Utah Ave
Idaho Falls, ID 83402

(208)701-2951

Fax: (208)701-2952

Mon, Wed, & Fri 7am-6pm
Tues & Thurs 8am-12pm

Ammon

3155 Channing Way D
Idaho Falls, ID 83404

(208)973-4170

Fax: (208)973-4171

Mon, Wed, & Fri 7am-6pm
Tues & Thurs 8am-12pm