*TEST Form

Sprains, Strains, or Injuries, we make getting the care you need easy.

Request an in-clinic or virtual appointment at a time that works best for you. Our Patient Experience Coordinator will use this info when they call to confirm your request.

Click here to learn how we protect your privacy.

First Name*

Last Name*

I am submitting this appointment request for my partner, child, parent or friend.

Their name*

Their Date of Birth*

Email*

Phone*

Your Date of Birth*

State*

Zip Code*

Clinic Location:*

I have a prescription from my doctor for:*

Physical Therapy
Occupational/Hand Therapy
I do not have a prescription

*You may be able to receive services without a prescription from your doctor. Our team will inform you when they contact you about your appointment.

*Now in Illinois, you no longer need a prescription for physical therapy.

*You no longer need a prescription for physical therapy.

Please list your doctor’s name*

Best Time to Contact You/Other Details:*

Other than a referring doctor, how did you hear about us?*

Please specify the name of the individual, event, organization or group*

Email and SMS Text Communication*

I agree to receive email and SMS text communication regarding appointment updates from Athletico Physical Therapy.
I agree to receive email marketing communication from Athletico Physical Therapy.

*By providing your phone number, you agree to receive text messages from Athletico and its service providers. Message & data rates may apply. Message frequency varies. You may reply STOP to a text message to opt out of receiving that type of message from Athletico or its service providers in the future. You may reply HELP to a text message for help. We take patient privacy seriously and do not sell your email or mobile numbers. Click here to learn how we protect your privacy, the terms of use and how to change email/text preferences.

Name

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