Physical Therapy Appointment Request

Request a Physical Therapy Appointment

RegisCARES: Clinical and Rehabilitation Services
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
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Current Regis StudentRegis Faculty/StaffRegis AlumniLocal Community Member
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Request a Physical Therapy Appointment