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Dixie Pics
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Home
About
What We Do
Our Mission
Partners
Services
Rehabilitation
Personal Care
Accomodations
Counseling
Work Placement
Sports and Equipment
Healthy Living
Education and Driving
Contact
History
Dixie Pics
Apply Now
Application for Enrollment
“
A journey of a thousand miles begins with a single step.
”
— Laozi
Please complete the following application and we will contact you soon.
Patient's Name
*
First Name
Last Name
Address
Phone
(###)
###
####
Email Address
*
Diagnosis
*
Date of Injury
MM
DD
YYYY
Date of Birth
MM
DD
YYYY
Physician's Name
Physician's Phone
(###)
###
####
Physician's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insurance Name
Subscriber Name
Policy Number
Patient is able to self-catheterize?
Yes
No
Patient is able to transfer independently?
Yes
No
Patient is independent in self-care e.g. showering, grooming, hygiene?
Yes
No
Patient is independent in bed mobility?
Yes
No
Patient is able to self-feed?
Yes
No
What type of mobility device does the patient use?
Does not use a mobility device
Manual Wheelchair
Power Wheelchair
Walker
Crutches
Cane
Additional Notes:
*
Thank you!
