Web Referral

Patient Referral Form

To refer a patient for virtual physical therapy, please fill out this secure form. The patient will be contacted to enroll, and we will share their progress with you at the information you provide.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Email
Patient Mobile Phone*
Please enter a valid phone number.
State

Street Address

Street Address Line 2

City

Zip Code
What is referral for?*

Virtual multidisciplinary care (physical therapy, nutrition counseling, and orthopedic evaluation)
Diagnosis/Condition*
Referring Name*

First NameLast Name
Referring Email*
Signature*

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Referring Practice Name*
Notes
By submitting this form, I understand that all clinical and physical therapy services will be provided by Protera Health Medical Group, P.C., which is an outpatient telemedicine-based provider.
By checking this box, you consent to receive sms/text messages from Protera. Reply STOP to opt-out anytime. TERMS and PRIVACY POLICY

SMS opt-in information and phone numbers for the purpose of SMS communication are not being shared.
Opt-in
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Patient Referral Form