Workers' Compensation Appointment

Please complete all of the information requested in the form below. Please note that the asterisk (*) items are required to complete your appointment request.

Once your request has been submitted, we will contact you. Appointments will be seen within 24 hours and in some cases the same day. Requesting an appointment for a NON work related injury? Use our Request an Appointment form.

Patient Information

Full Name:*

Address 1:*

Address 2:

City:*

State:*

Zip Code:*

Best Number to Contact the Patient:*

Email Address:*

Appointment Details

Preferred Provider:*

Preferred Location:*

Employer Information

Employer*

Contact*

Address 1*

Address 2

City*

State*

Zip Code*

Phone*

Referrer Information

Referral Source:*

Address 1:*

Address 2:

City:*

State:*

Zip Code:*

Phone:*

Fax:*

Insurance Information

Carrier:*

Address 1:*

Address 2:

City:*

State:*

Zip Code:*

Phone:*

Fax:*

Claim Number:*

Date of Injury - Month:*

Date of Injury - Day:*

Date of Injury - Year:*

Adjuster:*

Adjuster Phone:*

Adjuster Fax:*

Body Part:*

Authorized by:*

Do we contact this person for Authorization?* Yes No

Services Authorized

Number of visits authorized

from [date]

to [date]

Who should Total Body Physical Therapy email/fax records to?

Name:

Email or fax:

Name:

Email or fax: