Referral Form

You may call in referrals to 252-689-6043 or you may complete and fax this page to 252-364-2863. 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.

1 Step 1

Patient's Full Legal Name (Last, First, Middle)

Sex

MaleFemale

Patient Date of Birth

Diagnosis/Problem:

Insurance Coverage

Policy Number

Name of Parent or Guardian

Contact Phone Number

Services

Physical therapy evaluate and treatSpeech therapy evaluate and treatOccupational therapy evaluate and treatVital Stim/Feeding evaluation and treatAquatic 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.

Yes

Referring Provider's Name

Referring Providers's SignatureI agree to the terms and conditions

(Sign Here)

Clear Signature

Date

CA Provider Number

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We help your children develop properly and grow through hands-on learning and fun experiences

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Kinetic Pediatric Therapy Clinic

18 hours ago

Paige, COTA/L, and Angela, COTA/L, are back with a part 2 on pre-handwriting skills for kids! 📝Specifically, they speak on how #occupationaltherapist can help with:➡️ letter closure ➡️ uppercase and lowercase discrimination➡️ letter dissension We’re hallway through #OTMonth, and we’ve barely scratched the service of all what OTs do! 😁#OccupationalTherapy#OccupationalTherapyMonth ... See MoreSee Less

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Kinetic Pediatric Therapy Clinic

2 days ago

Wednesdays call for OT Trivia 😄 Comment your answer below! ⬇️American Occupational Therapy Association - AOTA #OTmonth#Kptwellness#Occupationaltherapy"OTs Help People Help Themselves." ... See MoreSee Less

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Kinetic Pediatric Therapy Clinic

3 days ago

Does your child struggle with:➡️ racking their food➡️ forming a fisted grasp when attempting to eat➡️ attempting to eat with an inverted spoonOur #occupationaltherapists can help you! Watch this clip to see how!For more information on our feeding therapy program, visit our website at www.kptkids.com#occupationaltherapy#OTMonth#feedingtherapy ... See MoreSee Less

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Kinetic Pediatric Therapy Clinic

6 days ago

Parents, are you looking for a fun, inexpensive, sensory activity for your child? Check this out! 🌈#occupationaltherapy#sensoryplay#OTMonth ... See MoreSee Less

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We help your children develop properly and grow through hands-on learning and fun experiences

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