Request Appointment

1Select Your Service

2Basic Information

3Schedule Date & Time

Which service are you requesting an appointment? *

Are you CURRENTLY receiving this service at Borja Physical Therapy? *

Yes, I want to schedule a follow up appointment
No

First Name *

Last Name *

Phone *

Date of Birth *

Gender *

Male
Female

Have you ever been a past client at Borja Physical Therapy? *

Yes
No

Welcome! How did you hear about us? *

Welcome back! How were your reminded of us this time around? *

When were you looking to start service? *

Immediately
Within 1 Week
Within 2-4 Weeks
Within 1-3 Months
>3 Months

Did you plan to use health insurance to cover the selected service? *

Yes, I plan to use health insurance
No, I plan on using cash or credit

Health Insurance Carrier *

If not listed, select Other.

Request Your Appointment *

Date

Time

Please Read: *

I understand that my selected date and time above is a 'request' and due to high demand, may need to be rescheduled. In the event where my appointment needs to be rescheduled, will be contacted by the phone number provided in this form.

Request Appointment

1Select Your Service

2Basic Information

3Schedule Date & Time

Which service are you requesting an appointment? *

Are you CURRENTLY receiving this service at Borja Physical Therapy? *

Yes, I want to schedule a follow up appointment
No

First Name *

Last Name *

Phone *

Date of Birth *

Gender *

Male
Female

Have you ever been a past client at Borja Physical Therapy? *

Yes
No

Welcome! How did you hear about us? *

Welcome back! How were your reminded of us this time around? *

When were you looking to start service? *

Immediately
Within 1 Week
Within 2-4 Weeks
Within 1-3 Months
>3 Months

Did you plan to use health insurance to cover the selected service? *

Yes, I plan to use health insurance
No, I plan on using cash or credit

Health Insurance Carrier *

If not listed, select Other.

Request Your Appointment *

Date

Time

Please Read: *

I understand that my selected date and time above is a 'request' and due to high demand, may need to be rescheduled. In the event where my appointment needs to be rescheduled, will be contacted by the phone number provided in this form.

Call Us 586-884-4565

Call Us 586-884-4565

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44656 Mound Road Sterling Heights, MI 48314© Copyright 2021 Borja Physical Therapy - All Rights Reserved

44656 Mound Road Sterling Heights, MI 48314© Copyright 2021 Borja Physical Therapy - All Rights Reserved

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