Request an appointment

Tell us about yourself and your availability for an appointment. We will phone you to schedule an appointment.

Please indicate which of our facilities you wish to attend:
LeRoy Physical Therapy
LeRoy Physical Therapy of Bergen
Gananda-Walworth Physical Therapy
Gates-Chili Physical Therapy
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:

Did you know? You can now see a physical therapist directly without a referral from a physician. Ask our staff for more information.

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:

 
 

------