Book a Telehealth Session Please complete the information below to allow us to set up a consultation with you. Your Name* First Last Email Address* Phone (optional)Your Home State* State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Date of Birth* Preferred Date* Specify the date you would prefer to have your appointment. We will confirm availability with you.Preferred Time* : HH MM AM PM Provide an approximate time for this appointment. We will try to fit your request to a 2 hour window around this time.Terms and Conditions* I agree to the terms below By clicking "I agree to the terms below", I understand that this physical therapy assessment will be conducted by a two way communication telehealth physical therapy platform and that my physical therapist has deemed this type of service appropriate and safe for the condition for which I am currently being treated. I understand that this telehealth service is a HIPAA compliant platform and that all safety and security measures to secure my protected health information have been instituted but I acknowledge the inherent risks of online transmission of data. I also understand that there is a chance that transmission of health information may be disrupted due to technological limitations outside of the telehealth platform This iframe contains the logic required to handle Ajax powered Gravity Forms. Share It!