This service should only be used to cancel or to change an existing appointment that is MORE than 24 hours away. If you need to cancel or change an appointment that is less than 24 hours away you should call our office at (732) 329-1181. You will get a call back from The Rehabilitation Center in about one business day. Online Appointment Services are easy to use, reliable, and available 24 hours a day.

 

Our online Appointment Services should ONLY be used for non-urgent appointment requests. If the patient feels that they have an urgent medical problem, call your physician's office or dial 911 immediately.

 

Your privacy is very important to us!  Therefore, to protect the confidentiality of the users of our site, all of the data that you type into one of our  "online" forms is encrypted before it leaves your computer and is not decrypted until it reaches our office.

 

* Required Fields

Sample form for use with formmail.php

Please select one:*

Request an Appointment

Cancel an appointment and reschedule

Cancel an appointment only
REQUESTER INFORMATION (May be the patient, patient's relative, caregiver or friend)

Please enter your first name:

   *

Please enter your last name:

 *
PATIENT INFORMATION  
  If same as above please skip to next section

Patient first name:

 *

Patient last name:

 *
PHONE NUMBERS  
  (Office will use these numbers to confirm request)

Preferred phone number:

 *Phone type:*

Alternate phone number:

  Phone type:
 
Image Verification
Please enter the text from the image
[ Refresh Image ] [ What's This? ]