Request a Rehabilitation Appointment

Request a Rehabilitation Appointment
After you submit this online form, our rehab scheduling department will call you within two business days to confirm your child’s appointment.

A written order/prescription from your referring physician is required for all outpatient rehabilitation services. You or your physician’s office can fax the order to the rehabilitation scheduling department at 404-785-7113.
Patient Information
Preferred appointment date (if available)*

MonthDayYear
Date
Referring Physician*

First NameLast Name
Referring Physician Phone*
Please enter a valid phone number.
Pediatrician*

First NameLast Name
Pediatrician Phone*
Please enter a valid phone number.
Rehabilitation Options
Has the child passed or had a normal hearing test or Auditory Brainstem Response (ABR) test within the past 12 months?
Complaint/Diagnosis*
Is the patient currently receiving this kind of therapy or have they had this kind of therapy recently?
Preferred Rehab Location
Preferred Rehab Location
Preferred Rehab Location
Preferred Rehab Location

Call Back Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Alt Phone Number
Please enter a valid phone number.
Select the most convenient day time to call back
Select the most convenient time to call back
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age in Years
Months
Sex
Language
What is the primary language spoken by your child?
What is the primary language spoken in the child’s home?
Marital Status
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.

Legal Guardian/Guarantor
Name*

First NameLast Name
Relation to Patient
Preferred language to discuss patient's healthcare information
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Confirm Email*
example@example.com
Employer Name
Phone Number
Please enter a valid phone number.

Secondary Contact
Name

First NameLast Name
Relation to Patient
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Employer
Work Phone
Please enter a valid phone number.

Emergency Contact
Name*

First NameLast Name
Relation to Patient
Phone Number*
Please enter a valid phone number.

Primary Insurance Information
Insurance Plan Name*
Insurance Plan Type
Policy Number*
Group Number*
Enter 00 for no group number
Name of Policy Holder*

First NameLast Name
Relation to Patient*
Insured Employee Status
Insured's Employer*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Benefits/Customer Service Number
Please enter a valid phone number.
Secondary Insurance?

YesNo

Secondary Insurance Information
Insurance Plan Name
Insurance Plan Type
Policy Number
Group Number
Enter 00 for no group number
Name of Policy Holder

First NameLast Name
Relation to Patient
Insured Employee Status
Insured's Employer

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Benefits/Customer Service Phone Number
Please enter a valid phone number.
Should be Empty: