Request an Appointment Request an Appointment Same-day appointments may often be available so please call your preferred clinic office if you want an appointment today. Columbus Physical Therapy: 402-564-5456 Humphrey Physical Therapy: 402-923-1011 Northeast Nebraska Physical Therapy - Norfolk: 402-371-8278 Name* First Last Date of Birth Date Format: MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime Phone*Cell PhoneEmail* Enter Email Confirm Email Best way of reaching you*-- Please select an option --Daytime PhoneCell PhoneEmailType of patient*NewExistingType of appointment*NewFollow-upReason for appointmentWho may we thank for referring you?Preferred location* Columbus Physical Therapy Humphrey Physical Therapy Northeast Nebraska Physical Therap Check which location is best for you.Preferred Day* First available Monday Tuesday Wednesday Thursday Friday Saturday Check which days are best.Preferred time* First available Early morning Mid-morning Afternoon Early evening Select the time that best suits your scheduleDisclaimer* I agree This form should not be used to communicate any confidential personal or medical information (PHI), but should only be used for appointment requests and general questions.
