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CONFIDENTIAL PATIENT INFORMATION3237 W. Truman Blvd, Ste 101 Jefferson City, MO 65109 5736366400 www.SpinalRejuv.com___ Patient Name (Please Print)PATIENT APPLICATION FORM Welcome to our clinic! We
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Start by gathering all the necessary information such as personal details, medical history, and insurance information.
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Visit the Discover Wellness & Rehab website and locate the patient registration form.
03
Fill out your personal details accurately, including your name, gender, date of birth, and contact information.
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Provide your medical history, including any previous illnesses, surgeries, or chronic conditions.
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Mention any medications you are currently taking, including dosage and frequency.
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If you have any allergies or specific diet restrictions, make sure to mention them.
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Specify your insurance details, including your insurance provider, policy number, and group number.
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Review the form for any errors or omissions before submitting it.
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Submit the filled-out form either online or by printing and mailing it to the Discover Wellness & Rehab address.
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If you have any questions or need assistance, contact the Discover Wellness & Rehab customer support for guidance.

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Discover Wellness & Rehab is suitable for individuals who require medical rehabilitation services.
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This includes individuals recovering from injuries, surgeries, or those with chronic conditions requiring specialized care.
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Anyone seeking physical therapy, occupational therapy, or other rehabilitative services can benefit from Discover Wellness & Rehab.
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Patients commonly referred by physicians or specialists in need of comprehensive rehabilitation can also opt for this facility.
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It is important to consult with a healthcare professional to determine if Discover Wellness & Rehab is appropriate for your specific needs.
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Discover Wellness & Rehab is a health and wellness center that provides various services to help individuals achieve their health goals.
Patients or clients who utilize the services of Discover Wellness & Rehab may be required to fill out forms related to their health and treatment.
To fill out Discover Wellness & Rehab forms, individuals typically provide their personal information, medical history, treatment goals, and any relevant health information requested by the center.
The purpose of Discover Wellness & Rehab is to assist individuals in improving their overall health and well-being through various therapeutic services and programs.
Information reported on Discover Wellness & Rehab forms may include personal details, medical history, current health issues, treatment plans, and progress updates.
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