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Center of Pelvic Excellence PT & Wellness 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 brings you to COPE at this time?
Required
Appointment Location
COPE PT Dallas - 12700 Hillcrest Rd Ste 149 Dallas TX 75230 | Monday - Thursday 8:30am - 5:30pm; Friday 8:30a- 4:30p
COPE PT Mckinney - 3721 S Stonebridge Drive Unit 1102 McKinney TX 75070 | Monday - Thursday 8:30am - 5:30pm; Friday 8:30a- 4:30p
Required
When are you available to come in?
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
Location
Other
Print Promo
Radio
Re-activation
Work Comp
Workshop
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 MEDICARE ADVANTAGE - AARP MEDICARE ADVANTAGE Plan
Aetna - Aetna
All Savers UHC - All Savers UHC Plan
ASR Health Plan - ASR Health Plan Plan
Blue Cross Blue Shield - BCBS
Blue Cross Blue Shield - BCBS HMO Plan
Blue Cross Blue Shield - Blue Advantage HMO Provider Network
Blue Cross Blue Shield - Blue Choice PPO Provider Network (Inclusive of Blue Precision/Blue Options)
Blue Cross Blue Shield - Blue Cross Medicare Advantage (HMO)
Blue Cross Blue Shield - Blue Cross Medicare Advantage (PPO)
Blue Cross Blue Shield - Blue Essentials Provider Network (HMO)
Blue Cross Blue Shield - Blue Premier
Blue Cross Blue Shield - HME - Health Select
Blue Cross Blue Shield - WEL - WellMed MA HMO
Blue Cross Blue Shield Medicare Advantage - Blue Cross Blue Shield Medicare Advantage Plan
Cigna - Cigna
Cigna True Choice Medicare Out of Network Benefits - Cigna True Choice Medicare Out of Network Benefits Plan
Gilsbar - Gilsbar Plan
Humana Out of Network Benefits - Humana Out of Network Provider Plan
Medicare TX - Medicare Part B
Meritain Health - Meritain Health Plan
MultiPlan Network - MultiPlan Insurance Plan
Multiplan- Health 360 - Health 360 Plan
PHCS Network - PHCS Network Plan
Scott and White Health Plan Tier 2 - BSW Employee Plan- Tier 2
Scott and White Health Plan Tier 2 - BSW Plus HMO
Scott and White Health Plan Tier 2 - BSW Plus PPO
Scott and White Health Plan Tier 2 - FC MyChoice PPO
Scott and White Health Plan Tier 2 - FirstCare Select Benefit Network
Scott and White Health Plan Tier 2 - HMO Enhanced Benefit Network
Scott and White Health Plan Tier 2 - Medicare (FC)
Scott and White Health Plan Tier 2 - PPO Limited Benefit Network
Scott and White Health Plan Tier 2 - Scott and White Health
Scott and White Health Plan Tier 2 - Scott and White Health EPO Plan
Scott and White Health Plan Tier 2 - Scott and White Health HMO
Scott and White Health Plan Tier 2 - Scott and White Health Medicare Advantage
Scott and White Health Plan Tier 2 - Scott and White Health PPO
Self Pay - Self Pay Plan
Superior HealthPlan Network- Medicaid - ALLWELL (MEDICARE)
Superior HealthPlan Network- Medicaid - AMBETTER
Superior HealthPlan Network- Medicaid - CHIP / PERINATE / RSA
Superior HealthPlan Network- Medicaid - MRSA
Superior HealthPlan Network- Medicaid - Medicare- Medicaid Plan MMP
Superior HealthPlan Network- Medicaid - STAR
Superior HealthPlan Network- Medicaid - Superior HealthPlan network Plan
Superior HealthPlan Network- Medicaid - Wellcare
Tricare East - Tricare East Plan
TriWest Healthcare Alliance - TriWest Healthcare Alliance Plan
UHC shared services - UHC shared services Plan
UHC Surest - UHC Surest Plan
UMR Health Insurance - UMR Health Insurance Plan
United American Insurance Company - United American Insurance Company Plan
United Health One - United Health One Golden Rule Insurance Company Plan
United Healthcare - AARP SUPPLEMENTAL PLANS INS BY UNITEDHEALTHCARE
United Healthcare - HMO - Medicare Risk
United Healthcare - New York State Empire Plan
United Healthcare - United Healthcare
United Healthcare - UnitedHealthcare Dual Complete (TX)
United Healthcare - UnitedHealthcare HMO
United Healthcare - UnitedHealthcare Medicare
United Healthcare - UnitedHealthcare Medicare Solutions
United Healthcare - UnitedHealthcare PPO
United Healthcare - UnitedHealthcare SignatureValue
United Healthcare - Zelis
US HEALTH GROUP a United healthcare - US HEALTH GROUP a United healthcare Plan
Wellcare TX - Wellcare by Allwell Plan
WellMed - Wellmed
Wellpoint formerly Amerigroup - Wellpoint 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
Password
Required
1. Length 12-30
2. One or More Upper AND Lowercase Characters
3. One or More Numeric
4. One or More of the following: !@#$%^&*()~:";<>?,./
Confirm Password
Required
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