Appointment Request New Patient Intake Forms Request an Appointment Our clinics are open to deliver on our promise of providing safe, affordable and effective rehabilitation services to all of our patients. After completing this form, a Physical Therapy Solutions staff member will contact you within 24 business hours to schedule your appointment. If you would like to fill out paperwork ahead of your appointment, you can find all forms below on our new patient page. New Patient Forms Request an Appointment First Name * Last Name * I am submitting this appointment request for my partner, child, parent or friend. Partner Child Parent Friend If you are submitting this request for yourself, please skip. Email * Phone * Date of Birth * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Clinic Location * Dyersville ClinicManchester ClinicDubuque Clinic I have a prescription from my doctor for * Physical Therapy Occupational/Hand Therapy I do not have a prescription Best Time to Contact * Other than a referring doctor, how did you hear about us? * Advertisment (Print, Radio, TV)PTS EmployeeCollegeClub Sport (Baseball, Hockey, Lacrosse, Rugby, Soccer, Volleyball, etc)Facility (Park District, Fitness Center, Sports Training Facility, etc)Golf OrganizationGymnastics/Cheerleading GroupHigh SchoolInfluencer Marketing ProgramInsurance CompanyOnline SearchPast PatientPerforming Arts/Dance GroupProfessional Sports TeamRace (Marathon, Half Marathon, Triathlon, 5K, etc.)Running/Biking Training GroupSocial Media By clicking this box you agree to receive email communication regarding appointment updates and marketing communication from Physical Therapy Solutions. * I agree Submit If you are human, leave this field blank. Δ
