:: Home

:: Freedom of Choice

:: Direct Access

:: Members Directory
     :: Buffalo area
     :: Rochester area

:: Locations Maps
     :: Buffalo area
     :: Rochester area

:: Request an Appointment

:: Links

:: Board of Directors

:: Members Only

 
Moving Forward with PT     
 
 
The Physical Therapy Alliance of Upstate New York
—— Request an appointment
Tell us about yourself and your availability for an appointment. We will be in contact with you to schedule an appointment.
Patient Information  
First Name: Last Name:
Date of Birth: Address:
City: State: NY Zip:
Phone Number: Email Address:
Insurance Information  
Primary Insurance Carrier:
* indicates a prescription and/or referral is required for insurance coverage

Referring Doctor's Name:

Primary Care Physician:

Diagnosis/Body Part:

Other: Please Specify:

Have you recently had surgery for this condition? Yes    No
Scheduling Needs:
Morning (7am-12pm ET)
Afternoon (12pm-5pm ET)
Evening (5pm-7pm ET)
Anytime
Additional Comments/Requests:

 



 

 


 
     
 
© Physical Therapy Alliance of Upstate New York