This service may be used to make a new appointment for one of your patients!  Your patient will get a call back from The Rehabilitation Center in about one business day.  Our online Appointment Services for medical practitioners is easy to use, reliable, and available 24 hours a day.

 

Our online Appointment Services should ONLY be used for non-urgent appointment requests. If the patient feels that they have an urgent medical problem, call your physician's office or dial 911 immediately.

Your privacy is very important to us!  Therefore, to protect the confidentiality of the users of our site, all of the data that you type into one of our  "online" forms is encrypted before it leaves your computer and is not decrypted until it reaches our office.

* Required Fields

Referring MD Appointment Request.php

 

Request an Appointment
REQUESTER INFORMATION (May be the patient, patient's relative, caregiver or friend)

Enter requester first name:

   *

Enter requester last name:

 *

Referring physician:

 *
PATIENT INFORMATION  

Patient first name:

 *

Patient last name:

 *
PHONE NUMBERS  
  (Office will use these numbers to make appointment)

Preferred patient phone number:

 *Phone type:*

Alternate patient phone number:

  Phone type:
 
Image Verification
Please enter the text from the image
[ Refresh Image ] [ What's This? ]