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Medical History Form (PDF)

New Patients:  To save time at your first appointment, click on the Medical History Form above, print and fill it out, then bring it to your first appointment.
Request an appointment online! After you click the submit button, someone from our friendly staff will contact you to confirm your appointment.

First Name:
 *
Last Name:
 *
Email Address:
Phone number:
 *
Best time for us to call you:
Day of week for Appt:
Time of day for Appt:
Reason for visit:
 *
Do not enter anything in this field:

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    Call us today to begin feeling better!

    Convenient to Raleigh/Cary and Surrounding Areas
    Visit us at Activcare Physical Therapy     
    3100 Blue  Ridge Road Suite 204
    Raleigh NC, 27612
    PH: (919) 782-5954
    FAX: (919) 782-6444