Pay Your Bill

Gray Physical Therapy is proud to sponsor an online bill paying system. To pay your bill in full or to make payments securely through PayPal, either a major credit card or a PayPal account is required.

After submitting your information below, you will be redirected to PayPal where you will input your payment information.

6 Turnpike Acres Road, Suite 2
PO Box 1047, Gray, Maine 04039

Tel: (207) 657-5600
Fax: (855)-464-0106
office@grayptcenter.com

Founding Members of:

Our Affiliate:
Premier Physical Therapy
316 Portland Rd
Bridgton, Maine 04009

Tel: (207) 647-2727

6 Turnpike Acres Road, Suite 2,
PO Box 1047, Gray, Maine 04039

Tel: (207) 657-5600
Fax: (855)-464-0106
office@grayptcenter.com

Our Affiliate:
Premier Physical Therapy
316 Portland Rd
Bridgton, Maine 04009

Tel: (207) 647-2727

Founding Members of:

Patient Medical History

Name:
Email:*
Date:
Date Format: MM slash DD slash YYYY
Do you have problems with your:
- eyesight
- hearing
- ability to read
- ability to write
Check if YOU have or have had any of the following:
- pace maker
- blood thinners
- high blood pressure
- high cholesterol
- heart disease
- chest pain
- blood relative under 55 who suffered a stroke or heart attack
- lung disease
- arthritis
- joint replacements
- diabetes
- migraine headaches
- epilepsy / seizures
- cancer
- broken bones ( fractures )
- osteoporosis
- stroke
- kidney disease
- liver disease
Have you fallen 2 or more times in the last year OR have you fallen one time resulting in injury?
- Yes
- No
List any recent (within last year) hospitalizations / reasons / dates:
List any recent surgeries and dates:
Medications and Supplements

Prescription Meds

Name	Reason (Pain, BP, Diabetes etc )	How Much (Mg)	How Often (per day or wk)	How Taken mouth, inject)

Over the counter Meds

Name	Reason (Pain, BP, Diabetes etc )	How Much (Mg)	How Often (per day or wk)	How Taken (mouth, inject)

Supplement (vitamins)

Name	Reason (Pain, BP, Diabetes etc )	How Much (Mg)	How Often (per day or wk)	How Taken (mouth, inject)

Medications I am alergic to:
Food and other things I am alergic to:
Height Weight

Pay Your Bill

Medications and Supplements

Emergency Contact

Your Employer

If Under 18 Years of Age:

BILLING / INSURANCE INFORMATION

If either of the Insurer’s listed above is Worker’s Comp or Motor Vehicle Accident related, please provide us with the Claim Handler’s Name, Telephone Number and your File / Claim Number.