Special Offer: Free Physical Therapy Consultation

It's simple to schedule a free Physical Therapy Consultation. You may either call our PT clinic at 847-562-0500 between 8:00am and 5:00pm (CT) Monday through Friday, or you can complete the following form and someone will call you as soon as possible.

Thank you for choosing Metrix Physical Therapy & Fitness!

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Your Information

*Patient Name:

*Home Address:

*City:

*State:

*Zip Code:

*Phone:

Alternate Phone:

Email:

*Date of Birth:

Occupation:

Date of Injury:

Diagnosis/Type
of Injury
(describe):

Have you previously seen a doctor for this injury?
Yes
No

If you are under the age of 18, please complete the following guardian contact information:
Guardian Name:

Relationship:

Phone:

If you are someone other than the patient or guardian and should be contacted in regard to this appointment request, please complete the following contact information:
Contact Name:

Email:

Phone: