Restorative Neurology Clinic

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Enrollment Form & Process - Upper Limb Program

STEP 1 – Complete all enrollment forms and membership agreement.

Please download the enrollment packet and complete the following enrollment forms:

  1. Screening Questionnaire
  2. Risk Review & Physical Approval From (for your physician to complete)
    Your doctor’s office can FAX your physician approval form to (914) 597-2796.
  3. Health Review Form
  4. Liability Waiver
  5. Membership Agreement

PDF iconrnc-enrollment-forms.pdf

STEP 2 – Return all forms to the Restorative Neurology Clinic by one of three options:

  • Email:
  • Fax: (914) 597-2796
  • Mail to:
    Burke Restorative Neurology Clinic – Robotics
    785 Mamaroneck Avenue, The Burke House
    White Plains, New York 10605

We will call to schedule an appointment only when all forms have been received.