Registration - Physical Medicine and Rehabilitation

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PHYSICAL MEDICINE AND REHABILITATION
Aquatic therapy program registration

Texas Children's Hospital is excited to introduce our pediatric aquatic therapy program. We provide both individualized treatment and group sessions focusing on learning to swim, group sports and activities and aerobic conditioning for all levels.

Child's name
Date of birth
Address
City, State, Zip
Parent or guardian
Contact numbers:
Home Work Cell
Best time and number to call
Child's diagnosis
What do you want your child to do better?
Physician's name
Physician's number
Insurance company
Address
City, State, Zip
Group or ID number
Contact number
Appointment preference:
Morning	Afternoon
Session interested in:
Individual	Group
Time of year:
Summer 2005 Fall 2005 Winter 2006 Spring 2006

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