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• Holy Name in Haiti

In This Section

• Center for Rehabilitation
• Physical Therapy
• Occupational Therapy
• Occupational Health Services
• Speech Therapy
• Pediatric Therapy
• Physical Therapy for Lymphedema
• Outpatient Programs
• Meet Our Therapists
• Sports Medicine
• Cardiac Rehabilitation
• HNH Fitness
• Orthopedic Services
• Medical History Form

Appointment Requests

• Schedule a Therapy

For More Information:

201-833-3085
Center for Rehabilitation

physicalrehab@holyname.org

Patient Stories

• Solomon Epstein

This Place is Different.

Schedule a Therapy

Patient Information

* Indicates required information

First Name: *	Last Name: *	Date of Birth: *  Month  January February March April May June July August September October November December  Day  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  Year  1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Email Address: *	Day Time Phone (M-F): * - -	Preferred Contact Method: *  Email        Phone
Clinical Information * Indicates required information
Therapy Type: * Select one Physical Therapy Occupational Therapy Speech Therapy Pediatric Therapy	Referring Physician: *	Insurance Plan Name: *
Have you had a therapy before? * Yes       No
If so, please indicate type of therapy, where, when?
Please explain your primary complaint: *
Comments or Questions:
Scheduling Preference Information * Indicates required information
Please indicate your appointment location preference: * Select one Center of Physical Rehabilitation - Teaneck Center of Physical Rehabilitation - Oradell No Preference
Please indicate your appointment date and time preferences:
First Preference Day:	First Preference Time Range: Select one 7:30 AM - 9:30 AM 9:30 AM - 11:30 AM 11:30 AM - 1:30 PM 1:30 PM - 3:30 PM 3:30 PM - 5:30 PM 5:30 PM - 6:30 PM
Second Preference Day:	Second Preference Time Range: Select one 7:30 AM - 9:30 AM 9:30 AM - 11:30 AM 11:30 AM - 1:30 PM 1:30 PM - 3:30 PM 3:30 PM - 5:30 PM 5:30 PM - 6:30 PM
Third Preference Day:	Third Preference Time Range: Select one 7:30 AM - 9:30 AM 9:30 AM - 11:30 AM 11:30 AM - 1:30 PM 1:30 PM - 3:30 PM 3:30 PM - 5:30 PM 5:30 PM - 6:30 PM
Please note: This online request form will not officially book your appointment at Holy Name Medical Center. You will receive a call back and/or an email to schedule the actual date and time within 48 business hours from your request. Submit Request