Physician Referral Form for Physical Therapy

Dear Physicians,

We are glad to share the same dedication for our patients. Being part of the healthcare community, we believe in efficient communication and teamwork. It would be our pleasure to work with you in the treatment of your patient.

Please send us your referrals! The patient whom you refer to us will experience only professional customer service from our staff. We ensure the privacy and confidentiality of the information that you forwarded to us through the form on this page.

Thank you for your trust.

Sincerely,
Omega Premier Team

Send us your referrals! The patient whom you refer to us will experience only professional customer service from our staff. We ensure the privacy and confidentiality of the information that you forwarded to us through the form on this page.

PATIENT INFORMATION

Patient Name (required):
Patient Phone (required):
Patient Email (required):
Date of Birth:

REFERRING PHYSICIAN

Referring Physician Name:
Physician Phone (required):
Physician Alt Phone:
Physician Fax:
Physician Email (required):
Referral Reason / Diagnosis:

Evaluation and Treatment

Manual Therapy:
Multiple selections are allowed "hold ctrl and click":

Therapeutic Procedures:
Multiple selections are allowed "hold ctrl and click":

Modalities:
Multiple selections are allowed "hold ctrl and click":

Patient Education:
Multiple selections are allowed "hold ctrl and click":

- (REQUIRED) - Please type in the security code and click Send.

Physical Therapy Referral – PDF file to complete

5 Physical Therapy & Rehab Clinics in Michigan:

Rochester Hills: 130 Hampton Circle, Suite 150, Rochester Hills MI. 48307
Roseville: 25509 Kelly Rd, Suite B, Roseville MI. 48066
Hazel Park: 23411 John Rd, Hazel Park MI. 48030
Dearborn: Prime Rehabilitation – 4953 Schaefer Rd, Dearborn MI. 48126
Sterling Heights: 2567 Metro Parkway Suite 101, Sterling Heights, MI 48310
Serving all of Oakland, Macomb and Wayne Counties.