Online Appointment Request

To schedule an appointment for yourself, please complete all of the information requested in the form below. Please note that the asterisk (*) items are required to complete your appointment request.

Once your request has been submitted, we will contact you within 24 hours (Monday – Friday) to schedule an appointment with your chosen provider.

Referring a patient from your practice to Total Body Physical Therapy? Use our Patient Referral Form. Requesting an appointment for a work related injury? Use our Workers’ Compensation Appointment Form.

We look forward to continuing to provide the expert care our patients have come to expect from Total Body Physical Therapy.

Patient Information

Full Name:*

Address 1:*

Address 2:

City:*

State*

Zip Code:*

Best Number to Contact You:*

Email Address:*

Primary Care Physician:*

Have you ever been seen at TBPT?* Yes No

Appointment Details

What problem will we be evaluating?*

Please give a brief description of your problem:*

Have you ever been evaluated for this problem before?* Yes No I don't know

Preferred Provider:*

Preferred Location*

Insurance Information

Primary Insurance:*