My Patient Needs Physical Therapy

Name:

Phone Number:

Date of Birth:

Insurance ID Number:

Attach Prescription ONLY PDF, TXT, JPG, JPEG, PNG & DOC(not .docx):

Which location would your patient prefer?

Who is making the referral?

We will contact your patient within 24 hours of receiving this referral.

Please leave this field empty.

Note*: we only accept .pdf, .txt, .jpg, .jpeg, .png or .doc, if you have a .docx file, please save as one of the allowed extensions and reattach.

PT United Medical and Therapy Equipment Source