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Aquatic Inquiry Form
Aquatic Inquiry Form
Date
MM slash DD slash YYYY
Has your child previously received care at any of St. Mary's Programs?
*
Yes
No
Patient Full Name
*
First
Last
Date of Birth (MM/DD/YY)
*
Gender
*
Male
Female
Address
*
Parent Information
Parent Full Name
*
First
Last
Home Phone
*
Cell Phone
Email
*
Preferred Method of Communication
*
Home Phone
Cell Phone
Email
Insurance Information
Does the patient have insurance?
*
Yes
No
Primary Insurance:
Secondary Insurance (if applicable):
Medical Information
Which of the following primary diagnoses applies to your child?
*
Torticollis
Cerebral Palsy
Neurological deficit
Post-Surgical
Orthopedic
Spinal Cord Injury/Acute Flaccid Myelitis
How long has your child had this diagnosis?
*
Please note a child is NOT a candidate if he/she has any of the following: Open wounds, Skin disorders/rashes, Tracheostomy/Vent, Central lines/PICC, Continuous Oxygen support.
*
My child does NOT have any of the above
Does child have any other medical condition/s? (Please list all)
*
If your child is a candidate, what time of day would be best for you?
WED 3:45 PM
WED 4:15 PM
WED 4:45
FRI 3:45 PM
FRI 4:15 PM
FRI 4:45 PM
How did you hear about us?
*
Δ
About
Our Mission
Our History
Our Leadership
Our Staff
Programs & Services
Inpatient Services & Long-Term Care
Rehabilitation
Aquatic Therapy
Neuro-Rehabilitation
Respiratory Therapy
Nursing
Healing Arts & Therapeutic Recreation
Complementary Care
Pediatric Feeding Disorders
Palliative Care
Respite Care
Spiritual Care
Spinal Cord Injury Rehabilitation
Day & Outpatient Services
Medical Day Healthcare Program
Center for Pediatric Feeding Disorders
Early Childhood Services
Helping Hands Summer Program
ABA Therapy at St. Mary’s Kids
Spinal Cord Injury Rehabilitation
Home Care
Care in the Home
Early Education
Special Needs Preschool
CPSE Evaluations
SEIT Services
Community Programs
Care Coordination Services
Community Care Professionals
Family Training
Free NYS Car Seat Inspections
For Families
Get To Know Us
Your Stay at St. Mary’s
Family Services
What to Expect
Visitor Guidelines
Resident Rights
Family Newsletter
Family as Partners in Care
Grievance Process
Ways To Give
Donate
Annual Fund
Corporate Giving
Planned Giving
Tribute Gifts
Special Initiatives & Campaigns
In-Kind Giving
Giving Societies
Friends of St. Mary’s
Volunteer
Giving Tuesday
Shop to Support
Greeting Cards
Why Give
Donor Stories
Your Impact
Patient Stories
Donate
Visitor Info
Contact & Locations
Careers
Events
News
Blog
Visitor Info
Contact & Locations
Careers
Events
News
Blog
English Link
[glt language=”English” label=”English”]
Employee Covid-19 Screening
Search
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