Schedule a Visit

***PLEASE do not fill out this form if you want to change or cancel your appointment, as messages are not seen on an immediate basis. YOU MUST CALL Phone: 402.817.0834 Fax: 402.817.0835 to reschedule appointment(s). Thank you!

First Name*

Last Name*

If submitting this appointment request for your partner, child, parent or friend:

Their Name

Phone

Email* Work Email:

I have a prescription from my doctor for* Select Physical Therapy Occupational/Hand Therapy I do not have a prescription