Referring Physician's Information:

*Referring Physician:

*Physician's Email:   

*Physician's Phone:  

Do you want confirmation of the appointment via email?  
  Yes    No

Do you want confirmation of the appointment via phone?
  Yes   No
Patient's Information:

*First Name:   

*Last Name:

*Patient's Phone:

*Is this a new BFOA patient?   Yes      No

*Patient's Insurance:

*Reason For Visit:

Physician Requested for Appointment: Please Select A Physician Arthur E. Thiel, MD Christopher A. Kontogianis, MD David W. Fischer, MD Heather L. Phipps, DO Michael C. Sherfey, DO Andres Garcia, Jr, PA-C No Physician Preference Physical Therapist

Location Preferred for Appointment:     Please Select a Location Main Office, Kennewick Dr. Fischer's Office, Kennewick Pasco Office PT Office, Kennewick

*Enter the letters from the box below (use lower case):

Reload Image

Make sure that all required fields (*) are filled in.