Patient Referral Form

Please use this form to refer a patient from your practice to Total Body Physical Therapy. Complete all of the information requested in the form below. Please note that the asterisk (*) items are required to complete your referral request. Once your referral has been submitted, we will contact the patient within 24 hours (Monday – Friday) to schedule an appointment.

Referring a patient for a work related injury? Use our Workers’ Compensation Appointment Form.

We look forward to continuing to provide the expert care you have come to expect from Total Body Physical Therapy.

Referring Physician Office Information
Patient Information
Medical Information