Physical Therapy Referral
To refer a patient, simply complete our online referral form or contact Central Scheduling at (312) 878-8800 or fax your prescription to (312) 448-9978.
We ensure a smooth and efficient referral process for both you and your patient.
Online Referral Form
Patient Name: *
DOB: *
Patient Phone Number *
Patient Email
Preferred Facility
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ICD-10 Dx Code: *
Precautions & Physician Comments:
Services *
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Physician Signature *
Date:
Submit