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Center of Pelvic Excellence PT & Wellness Portal
Recaptcha v3
New client registration form
E-Mail - This will be your Username
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Required
Birthday
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Expected format: MM/DD/YYYY
Required
What brings you to COPE at this time?
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Required
Appointment Location
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Main Office - 3721 S Stonebridge Drive Unit 1102 McKinney TX 75070 | 8:30a - 5:30p Monday- Friday
Required
When are you available to come in?
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Required
Referring Provider
First Name
(Value Required)
Required
Middle Name
Last Name
(Value Required)
Required
Gender
(Value Required)
Female
Male
Required
How did you hear about us?
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Client Referral
Doctor
Email
Facebook
Google
Location
Other
Print Promo
Radio
Re-activation
Work Comp
Workshop
Yelp
Required
Home Address
(Value Required)
Required
Apt, Ste, or Floor (Optional)
City
(Value Required)
Required
State
(Value Required)
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
(Value Required)
Required
Phone Number
(Value Required)
Required
Phone Type
(Value Required)
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
Blue Cross Blue Shield - BCBS
Boomy Health - Boomy Health Plan
Bright HealthCare - Bright HealthCare Plan
Cigna - Cigna
Gilsbar - Gilsbar Plan
Medicare TX - Medicare Part B
MultiPlan Insurance - MultiPlan Insurance Plan
Multiplan- Health 360 - Health 360 Plan
Scott and White Health Plan - Scott and White Health
Self Pay - Self Pay Plan
UHC shared services - UHC shared services Plan
United American Insurance Company - United American Insurance Company Plan
United Healthcare - AARP SUPPLEMENTAL PLANS INS BY UNITEDHEALTHCARE
United Healthcare - United Healthcare
Member ID
(Value Required)
Required
Group Number
Are you the policy holder?
(Value Required)
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
(Value Required)
Required
Policy holder Middle Name
Policy holder Last Name
(Value Required)
Required
Relationship to insured
(Value Required)
Child
Other
Spouse
Employee
Unknown
Life Partner
Mother
Required
Policy holder Gender
(Value Required)
Female
Male
Required
Policy holder Birthday
(Value Required)
Expected format: MM/DD/YYYY
Required
Policy holder Address
(Value Required)
Required
Policy holder Suite, PO Box, etc.
Policy holder City
(Value Required)
Required
Policy holder State
(Value Required)
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
(Value Required)
Required
Password
Password
(Value Required)
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
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