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Name

First Name

Last Name

Phone

(###)

###

####

Insurance Provider

Body Part Needing Therapy

Do you have a referral from a Doctor?

Yes

Select Clinic of Choice

How did you hear about us?

Message

Request An Appointment

Please note: this form cannot be used to cancel appointments. To cancel your appointment, you must call your clinic or central scheduling. (260-209-2464)

Request Appointment

Request An Appointment

Indiana Physical Therapy