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. This iframe contains the logic required to handle Ajax powered Gravity Forms.
