Appointment Request

Contact Appointment Request Appointment Change Request

Senior couple outside

Please complete the following information to make a request for an Initial Examination. Our patient coordinator will call you within 1-2 business days. All requests made Friday afternoon will be addressed on Monday. Please review updated clinic hours/closures on Google/Yelp as this may affect callback response time.

Please note: Our office is closed on Tuesdays, Saturdays and Sundays.

Name*
First Last
Phone*
Email*
Date of Birth*
Preferred Days*
- Monday
- Wednesday
- Thursday
- Friday
Preferred Time of Day*
- Morning (8:30am - 11:30am)
- Afternoon (2:30pm - 3:30pm)
Insurance Company Name and Type*
Insurance Member/ID # (Please include any letters)*
Side of body
- Left
- Right
- Both
Body Region*
- Hip
- Knee
- Foot/Ankle
- Hand/Wrist
- Elbow/Shoulder
- Neck/Upper Back
- Mid/Lower Back
Surgery Type and Date of Surgery (if applicable)
Full Name of Referring Physician
Image of Prescription (if available)
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.
Please note that our clinic has emotional support animals on site. Do you have any concerns or fear of dogs?*
- Yes
- No
If yes, we can ensure the dogs are on a leash during your visit.
Comments or Questions
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Phone
This field is for validation purposes and should be left unchanged.

Location

194 Francisco Lane Suite 104
Fremont, CA 94539
P: (510) 656-3777
F: (510) 656-3750
Front desk email: frontdesk.ESPT@gmail.com

Quick Links

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Graduate Internship Program
Request an Appointment
Change/Cancel Appointment

Hours

Mon, Wed, Fri: 8:00am-5:00pm*
Thur: 8:00am-1:00pm

*Office closed daily from 1-2pm
Last appointment one hour before closing
Closed: Tuesday, Saturday, Sunday