Is Dynamic the Right Fit for Your Therapy Services?

Is Dynamic the Right Fit for Your Therapy Services?
Date

MonthDayYear
Date
All information entered is via a HIPAA secure site.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Town of residency*
Pennsylvania
Primary medical insurance*
Please state briefly why you are looking for therapy services. Then if you can please take a moment and check off the answers below as part of our screening process for your interest in services.*
Were you recently discharged from a hospital, facility, or homecare nursing /therapy services?*

YesNo
Are you looking to supplement therapy services from another therapy company?*

YesNo
Is transportation to outside appointments a challenge?*

YesNo
I am interested in receiving therapy sessions:*

in the comfort of my homevia teleheathat the clinic in Berwyna mixture of the aboveunsure
Are you having difficulty walking because of weakness, pain, dizziness, balance, or fatigue?*

YesNo
Have you had any recent falls?*

YesNo
Are you a caregiver looking for training for caring for your loved one?*

YesNo
Do you need a home safety assessment including equipment needs?*

YesNo
Are you having difficulty in activities of daily living, such as bathing, dressing, getting in/out of bed?*

YesNo
Have you noticed a change in your speech or swallowing?*

YesNo
Has there been a change in your cognition (memory, processing)?*

YesNo
Please submit your information, and one of our staff will reach out for an introcuctory call to learn more about your needs for specialized services. Thank you for your time and interest.
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Is Dynamic the Right Fit for Your Therapy Services?

All information entered is via a HIPAA secure site.