Full Name (Required)

Date of Birth (Required)

Email (Required)

Phone Number(Required)

Payment For Services
In-Network Benefit Through Medicare.Self-Payment, with the option to submit to my insurance plan for reimbursement under any applicable Out-Of-Network Benefits that I may have.I am not sure of my coverage.

Do you have a prescription or referral from your doctor?
YesNo

Who is your referring doctor?
(If you are unsure of the doctor’s full name, a last name or the practice/group name is helpful as well)

Office Location Preference(Required)
ClayDewittLiverpool

Contact Preference (Required)
EmailPhoneText Message

Additional Notes
(Provide us any additional information you want us to have to help you schedule.)

By checking this box, I confirm that my patient information is true and accurate. I certify that I am not soliciting for sales, marketing or pitching a business-related inquiry through this form. I am submitting this form as a prospective patient requesting an appointment or asking a question related to Physical Therapy services or insurance coverage only. Sales, Marketing and other business-related inquiries should be made directly to marketing@myphysioone.com.