Bridge2PT Physical Therapist Information

Please fill out the following information so that we can build your PT Profile with Bridge2PT!

* Indicates required question

First and Last Name with Designations*

Enter your name exactly how you'd like it to be displayed on your profile, for example: John Smith PT, DPT, OCS, FAAOMPT... *

Email Address for Login*

We'll only use this in our communications with you and to build your scheduling/documentation profile. Patients will NOT have access to your email. *

Phone number*

We'll only use this in our communications with you and if you'd like to receive text message notifications about your appointments. Patients will NOT have access to your phone number. *

Physical Address for Building Your Service Area - Include City and Zip Code*

We'll only use this address to build a Service Area Map around your preferred location. Patients will NOT have access to this address. The default radius for service area is roughly 15 miles around the address you provide, please indicate below with your address if you'd like to use a different radius or if there are certain cities/zip codes you would like to include or leave out of your Service Area Map. *

Bridge2PT Physical Therapist Information

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This is your opportunity to set yourself apart from other PT's on the site and personalize the services you offer. Use these sections to show what makes YOU the best choice for potential patients!

SET YOUR OWN PRICE here for your 60 min Mobile Physical Therapy Sessions. *

This price will be displayed to your patients, and it is the price they will pay for an appointment.

The default price is set at $250 for a one hour session. We encourage you to set your price at what you feel is best for you and your community. You can change your price at any time, as well as find additional options for customizing your appointment types, durations, and prices at https://bridge2pt.lpages.co/for-pts/#change-priceappt-types. *

PT Bio/Specialties (required for profile completion)

We understand if this feels daunting, and we don't want it to hold you back from creating your profile. If you'd like to take some time to develop your bio, leave this section blank and we'll reach out to you for it.

Please list any languages you speak other than English*

Please indicate NONE if no other languages spoken. *

Bridge2PT Physical Therapist Information

* Indicates required question

You must hold a valid and unexpired Physical Therapy State License and Professional Liability Insurance to provide care to patients through the Bridge2PT Platform. Please upload your information below.

Document Submission Method*

We require copies of your Physical Therapy State License, Professional Liability Insurance, and a profile photo. In order to use this form to upload the required documents, you must be logged in to a Google account. If you do not have a Google account or you would like to submit your information via email, please select the email option below and submit your copies via email. *

I will attach the required files below

I will email the required files to [email protected]

Please upload a copy/picture of your Physical Therapy License. Be sure the STATE OF LICENSURE, your NAME, your LICENSE NUMBER, and the EXPIRATION DATE are all clearly visible.

Upload 1 supported file. Max 100 MB.

What is the Expiration Date on your current PT License? (required for profile completion)

Date

Professional Liability Insurance (required for profile completion)

Please upload a copy of your Professional Liability Insurance. Be sure the INSURANCE CARRIER, POLICY NUMBER, EXPIRATION DATE, and PROFESSIONAL LIABILITY LIMITS are listed on your insurance certificate. If you need assistance with this, please contact us here https://bridge2pt.lpages.co/contact-us/

Upload 1 supported file. Max 100 MB.

What is the Expiration Date on your current Professional Liability Policy? (required for profile completion)

Profile Picture (required for profile completion)

Please upload a picture of yourself to use as your profile picture. Yours should be the only face in the picture, please use a high quality image if possible.

Upload 1 supported file. Max 100 MB.

Bridge2PT Physical Therapist Information

* Indicates required question

Please read and agree to the following by checking the boxes * *

I currently hold both a valid and unexpired Physical Therapy State License and Professional Liability Insurance

I agree to adhere to all HIPAA Laws and Regulations before, during, and after all treatments arranged via the Bridge2PT platform

I have read and agree to the Bridge2PT Physical Therapist Terms of Use https://bridge2pt.com/pt-terms-of-use/

Is there anything else you'd like to tell us or that we can help you with?