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Infinite Rehab and 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 concerns do you have that you want to address?
Required
Appointment Location
189 W University Parkway Jackson TN 38305
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 Supplement Plan - AARP Medicare Supplement Plan Plan
Aetna - Aetna Plan
Bankers Fidelity - Bankers Fidelity Plan
Blue Cross Blue Shield of Florida - Blue Cross Blue Shield of Florida Plan
Blue Cross Blue Shield of Illinios - Blue Cross Blue Shield of Illinios Plan
Blue Cross Blue Shield of Michigan - Blue Cross Blue Shield of Michigan Plan
Blue Cross Blue Shield of Tennessee - Blue Cross Blue Shield of Tennessee Plan
High Mark Blue Cross Blue Shield - High Mark Blue Cross Blue Shield Plan
Humana - Humana Plan
Medicare - Medicare Plan
Tricare For Life - Tricare for Life Plan
UHC Medicare Advantage - United Healthcare Medicare UHC Medicare Advantage Plan
UMR - UMR 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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