Sign Up for Physical Therapy, Pain Management and Wellness Services

The ActiveRx Experience

At ActiveRx®, you'll be in the care of a highly qualified team of dedicated professionals whose common goal is working with you to proactively achieve and sustain a more functional and active lifestyle.

Being independent gives you life choices that you otherwise would not have.

Choose ActiveRx®.

Choose How You Age.

To get things started just provide us some basic information. Once submitted, our system will receive your information and we will contact you to confirm an appointment. You can download the rest of the forms to get a head start on things, too by clicking the links below.

* indicates required field.

Patient Information

Patient Name *

Patient E-mail *

Patient Phone Number *

Patient Date of Birth *

Month

Day

Year

Referral Information (If Applicable)

Referrer name

Referrer E-mail

How did you hear about us?

Which clinic would you like to visit? *

Insurance Information

Insurance Carrier

Policy/ID#

I (or the patient) have secondary insurance

I give ActiveRx permission to verify my (or the patient's) insurance benefits

ActiveRx® Clinic Locations

Phoenix, AZ

ph 602.242.1909

fax 877.375.0934

Scottsdale, AZ

ph 480.443.0409

fax 480.704.4763

Sun City West / Surprise, AZ

ph 623.544.7138

fax 623.565.8929

The ActiveRx Experience

Sign Up for Rehabilitation and Wellness Services

ActiveRx® Clinic Locations

Phoenix, AZ

Scottsdale, AZ

Sun City West / Surprise, AZ

Sun Lakes / Chandler, AZ