Physical Therapy Appointment Request

Request a Physical Therapy Appointment

RegisCARES: Clinical and Rehabilitation Services
Para traducir este formulario al español, haga clic en el menú desplegable de arriba.
Name*

First NameLast Name
Date of Birth

MonthDayYear
Gender*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Zip Code*
Name of Insurance Company/Provider
Insurance Member/Subscriber ID
Preferred Appointment Times*

MorningsAfternoonsEvenings
Description of Physical Therapy Needs
I am a:*

Current Regis StudentRegis Faculty/StaffRegis AlumniLocal Community MemberTepeyac Referral
Please upload any relevant documents such as a picture of your insurance card or referral.

Browse Files

Cancelof
By submitting this form, I agree to the Regis University Privacy Policy and the Regis University Terms of Use.
Should be Empty:

Request a Physical Therapy Appointment