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Live Life Physiotherapy Portal
Install App
Recaptcha v3
New client registration form
E-Mail - This will be your Username
Required
Birthday
Expected format: MM/DD/YYYY
Required
What Condition Are You Seeking Treatment For Today?
Required
Appointment Location
8622 Argent St. Suite F Santee CA 92071
Your Home Alpine CA 91901
Your Home El Cajon CA 92019
Your Home El Cajon CA 92020
Your Home El Cajon CA 92021
Your Home Jacumba CA 91934
Your Home La Mesa CA 91941
Your Home La Mesa CA 91942
Your Home Lakeside CA 92040
Your Home Lemon Grove CA 91945
Your Home Poway CA 92064
Your Home Ramona CA 92065
Your Home San Diego CA 92119
Your Home San Diego CA 92124
Your Home Spring Valley CA 91977
Your Home Spring Valley CA 91978
Required
Referring Provider
First Name
Required
Middle Name
Last Name
Required
Gender
Female
Male
Required
How did you hear about us?
Client Referral
Doctor
Email
Facebook
Google
Other
Print Promo
Radio
Work Comp
Yelp
Required
Home Address
Required
Apt, Ste, or Floor (Optional)
City
Required
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Required
Zip Code
Required
Phone Number
Required
Phone Type
Cell
Home
Work
Required
Insurance - If applicable
Self Pay / No Insurance
AARP - AARP Plan
Aetna - Aetna Plan
Aetna Medicare - Aetna Medicare Plan
Anthem - Anthem Medicare Supplement
Anthem - Anthem Plan
Anthem Medicare Supplement - Anthem Medicare Supplement Plan
BCBS Fed Employee - BlueCross BlueShield Federal Employee Program Plan
Blue Shield of California - Blue Shield of California Plan
Blue Shield of California Supplement - Blue Shield Supplement Plan
California Medicaid - California Medicaid Plan
Combined Insurance - Combined Insurance Plan
CSI - CSI Plan
GEHA - GEHA Plan
Health Net Supplement - Health Net Supplement Plan
Humana Medicare Supplement Plan G - Humana Medicare Supplement Plan G Plan
Kaiser - Kaiser Plan
Medicare - Medicare Plan
Molina Healthcare - Molina Healthcare Plan
Other - Other Plan
Tri Care for Life - Tri Care for Life Plan
UHC Medicare - United Healthcare Plan
UNITED OF OMAHA LIFE INSURANCE COMPANY - UNITED OF OMAHA LIFE INSURANCE COMPANY Plan
Member ID
Required
Group Number
Are you the policy holder?
Yes
No
Required
I have a secondary insurance policy and will provide details upon arrival
Other Insured
Please provide the policy holders information. For example, if this is your spouses policy you would enter their information in the corresponding fields below.
Policy holder First Name
Required
Policy holder Middle Name
Policy holder Last Name
Required
Relationship to insured
Child
Other
Spouse
Employee
Unknown
Life Partner
Mother
Required
Policy holder Gender
Female
Male
Required
Policy holder Birthday
Expected format: MM/DD/YYYY
Required
Policy holder Address
Required
Policy holder Suite, PO Box, etc.
Policy holder City
Required
Policy holder State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Required
Policy holder Zip Code
Required
Password
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