Physical/Occupational Therapy Referral Form

Quick Links:

Referring physician offices can now upload patient records when submitting web referrals. Click link on the bottom of the page to upload records and orders.

Referring Physician*
Referring Contact Person*
Referring Contact Phone*
Referring Contact Email*
Patient First Name*
Patient Middle Initial
Patient Last Name*
Patient Phone #*
Patient DOB (mm/dd/yyyy)
Problem Areas Back / Neck
Hip
Hand / Wrist
Foot / Ankle / Podiatry
Shoulder / Arm
Knee / Leg
Other:
Affected Side
Duration/Frequency Times Per Week Weeks
Diagnosis
Comments
Insurance
Authorization # If Required
Click Here To Attach Patient Records
(PDF, DOC/DOCX and JPG file types accepted)


Please fax signed corresponding therapy prescription to 919-220-6379.

"Being able to access your Orthopedic Urgent Care on a Saturday was a God-send. It was wonderful to avoid an ER. Thank you all so much for being open on Saturdays and after hours, Monday through Friday."

"Being able to access your Orthopedic Urgent Care on a Saturday was a God-send. It was wonderful to avoid an ER. Thank you all so much for being open on Saturdays and after hours, Monday through Friday."

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