Rehabilitation Medicine Clinic Appointment Request
Please fill out the form below to request a patient evaluation for an appointment or referral request.
Have your healthcare provider fax a referral to 404-603-4509.
Patient Information
First Name
Last Name
Date-of-Birth
Email
Phone
How was the patient referred:
Please select...
Word of Mouth
Online Search
Healthcare Provider
Other
Type of Insurance
Please select...
Commercial: (e.g. Aetna, Cigna, Blue Cross/Blue Shield, etc.)
Medicare
Medicaid
Which Injury/Injuries Apply:
Please select...
Spinal Cord Injury
Acquired Brain Injury
Both
What services is the patient looking for?
Medical Management
Occupational Therapy
Physical Therapy
Speech Therapy
Psychology
Other
If other, please describe:
Please describe the patient's reason for requesting an appointment:
Has a doctor referred the patient?
Please select...
Yes
No
Referring doctor's name:
Date of Injury
Has the patient been to Shepherd Center before?
Please select...
Yes
No
Caregiver Information
Is this form being submitted by a caregiver?
Please select...
Yes
No
First Name
Last Name
Email
Phone Number
Contact Information