Request An Appointment

Request an Appointment

Please complete the form below, and a Tri Rivers scheduler will contact you as soon as possible and no later than 5 p.m. the next business day to schedule your appointment.

Appointment Request

Last Name

First Name

Middle Initial

Parent/guardian if patient is under 18

Address 1

Address 2

City

State

Zip Code

Health Insurance Company

Home Phone

Birth Date

Who is your primary care physician?

Please briefly describe the nature of your orthopedic or physical medicine concern. If you were injured, please describe how and where your injury occurred.

Is your injury related to an automobile accident?

Yes

Is your injury work-related?

Yes

Date of Injury?

Who is scheduling this appointment?

Contact Name

Contact Number

Free Text

Click “Submit” to complete your appointment request through our secure form. A member of our staff will contact you at the number indicated above to schedule your appointment as soon as possible, but no later than 5 p.m. the next business day.