Total Rehab, P.C.

Schedule an Appointment



Fields marked with a * are required.
location:
patient information
patient name:*
home address:*
city/state/zip:*
best time to reach you:		best method to reach you:
day time phone:*	- -	alternate phone:	- -
Email*:
SSN:		Date of Birth:*
occupation:
date of injury:*		diagnosis / body part:
If the patient is under 18, please complete the following guardian contact information:
parent/guardian name:
relationship:		phone:	- -
If you are someone other than the patient or guardian and should be contacted in regards to this appointment request, please complete the following contact information:
contact name:
email:		phone:	- -

Total Rehab Center accepts all major insurance plans. Our business staff will assist in the filing of insurance claims.
PLEASE SELECT A TYPE OF INSURANCE


Refering Physician
Individual Submitting Appointment Request:*
physician name:*
address:
city/state/zip:
phone:*	- -	fax:	- -
employment
employer name:
supervisor name:
job title:
address:
city/state/zip:
phone:	- -	fax:	- -
claim adjuster
claim adjuster name:
company name:
address:
city/state/zip:
phone:	- -	fax:	- -
email:
claims adjuster (third party administrator)
claim adjuster name:
company name:
claims mailing address:
city/state/zip:
phone:	- -	fax:	- -
email:		claim number:

patient information