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Please fill out the following form to help us understand your physical condition.

First Name

Last Name

Email Address

Date of Birth

Phone

Full Address

Primary Insurance

Secondary Insurance

Physician

Reason for Therapy

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THE CLINIC

Address

800 N. 8th Street

Clear Lake, IA 50428
Phone

641-357-0012

Fax

641-357-0021

Hours

Mon - Thurs: 7am - 5pm

Fri: 7am - 12pm

Sat - Sun: Closed

Email

NPI #

1528667029

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