Virtual Physical Therapy

1
Getting Started

To best serve you, we will collect the information required to get you set up. Then, we'll ask you questions about your condition, pain, and limitations. All the information will be provided to your Physical Therapist before your visit.

Approximate time to completion: 10 minutes.
2
Are you new to our practice?* This field is required.Will this be your first time seeing us, or have we treated you before?
Yes, I'm new.
No, I'm returning.
3
Who are you requesting an appointment for?* This field is required.We're happy to provide care to you and your entire family. Please let us know if you're filling this request out for yourself or on behalf of a child or dependent.
Myself
A child or dependent
4
Your Full Name
First Name
Last Name
5
Date of BIrth
Date
Month
Day
Year
6
Phone Number
Please enter a valid phone number.
7
Your Email Address
example@example.com
8
Home Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Kentucky
Louisiana
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Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
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Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
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Kuwait
Kyrgyzstan
Laos
Latvia
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Lesotho
Liberia
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Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
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Samoa
San Marino
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Saudi Arabia
Senegal
Serbia
Seychelles
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eSwatini
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Tanzania
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Tonga
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Tristan da Cunha
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Turkey
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Vanuatu
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Thanks! The final steps:

We'll guide you through questions about your current status and condition. The information will be provided to your Physical Therapist before your first visit.
10
How can we help you today?* This field is required.
Reduce Pain
Restore Function
Return to Sport
Prepare for Surgery
Recover from Surgery
Prevent Future Injury
Improve Overall Health
Other
11
Are there any particular body regions that you'd like to focus on?* This field is required.
Neck
Mid-Back
Low Back
Shoulder
Elbow
Wrist/Hand
Hip
Knee
Ankle
Foot
Head
Other
12
Select which of the following symptoms (if any) you are experiencing* This field is required.
Aches, Soreness, Pain
Loss of Strength
Stiffness
Difficulty performing daily tasks
Inability or restriction with sports
Numnbess or Tingling
Dizziness/Vertigo
Balance Issues/Falling
I'm not experiencing any symptoms
13
Which of the following best explains how your symptoms began?If post-surgical, choose the option that best explains the original onset of symptoms.
With a specific activity (e.g. with execise, sports, on the job, around the house)
Traumatic Event (e.g. Car accident, a fall from height, or an aggressive sports injury)
Unknown cause, immediate onset (e.g. you just woke up with symptoms)
Unknown cause, gradually developing over time (it's been this way or getting worse)
14
Did the event that caused your symptoms occur within the last 3 months?if post-surgical, choose the option that best explains the original onset of symptoms.
YESNO
15
Did the event that caused your symptoms occur within the last 7 days?
YESNO
16
Have you recently experienced any of the following symptoms?
Unexplained weight loss
Progressive weakening
Fever
Bowel or Bladder Issues
None of the above
17
Before submitting please verify* This field is required.
18
Great! Let's find an appointment that works for you.

You agree to Buffalo Rehab Group's Financial Policy and Consent to Treat by submitting this form.
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Getting Started

Thanks! The final steps:

Great! Let's find an appointment that works for you.