Book an Appointment Email 1REASON FOR REQUEST2APPOINTMENT DETAILS3PATIENT INFO LinkedInThis field is for validation purposes and should be left unchanged.Patient Name First Last Cell Phone*Email Select all the areas that are causing you pain: Neck Mid Back Low Back Hip Ankle Shoulder Wrist/Hand Elbow Knee Foot Preferred Days of the Week: Monday Tuesday Wednesday Thursday Friday No preference Preferred Appointment Time: Morning Afternoon Evening No preference How did you hear about us?:*Please selectMagazine-NewspaperTVEmailFacebookGoogleSocial MediaReferralAnything else you would like to let us know?Consent* I agree to the privacy policy. I acknowledge that information submitted through this form will be sent via email, which is not a secure messaging system. Please refrain from sharing private health information here as we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form. This form is for appointment requests only. To confirm your appointment, one of our patient access representatives will contact you for insurance details, coverage verification, and benefits discussion. No doctor's referral is needed for consultations or treatment. Please note we accept out-of-network payments from many commercial carriers, we are in-network with Medicare, and we do not accept Medicaid. By sharing your phone number, you agree to receive SMS from Performance Ortho. Standard rates apply. For data handling details, visit here. We do not share your mobile info with third parties, except for text messaging originator opt-in data, which remains confidential.*
