Referral Form     Kinetic Pediatric Therapy  1330 East Arlington Blvd  Greenville, NC 27858

You may call in referrals to 252-689-6043 or you may complete and fax this page to 252-354-2863.  Thank you for allowing us to care for your patient / child.   If you choose to fax the referral, we will contact you to advise you of the appointment date and time after we contact the parent or guardian to schedule.

Patient’s Full Legal Name: (Last, First, Middle)

___________________________________________________________________

Sex:   ____ Male    ____ Female

Patient Date of Birth:

___________________________________________________________________

Diagnosis / Problem:

___________________________________________________________________

Insurance Coverage and Policy Number:

___________________________________________________________________

Name of Parent or Guardian:

___________________________________________________________________

Contact Phone Number: ________________________

Services:

____ Physical Therapy Evaluate and Treat

____ Speech Therapy Evaluate and Treat

____ Occupational Therapy Evaluate and Treat

____ Vital Stim / Feeding Evaluation and Treat

____ Aquatic Physical, Occupational Therapy Evaluate and Treat (indoor heated therapy pool onsite)

____ Other ____________________________________________________________

I certify this patient is under my care and these services are medically necessary.

Referring Provider’s Name __________________________________________________

Referring Provider’s Signature and Date _________________________________________