Patient Intake Form

Patient History

Medical History

Please complete the form in its entirety before your appointment.

DOB:

Medications & Allergies

Past Medical History

PSA:
WaveTech Therapy Birmingham

WaveTech Birmingham
2100 Southbridge Parkway Suite 260
Birmingham, AL 35209

Phone (205) 777-3736

Fax (205) 224-4747

birmingham@wavetechtherapy.com

Military Discount

WaveTech Therapy Military Discount