Visit / Procedure Information

Preferred appt. date (if available)

Referring Physician's First Name

Referring Physician's Last Name

Phone Number

. .  

Pediatrician's First Name

Pediatrician's Last Name

Phone Number

. .  

Rehabilitation Options

Physical Therapy Evaluation Occupational Therapy Evaluation Speech Therapy Evaluation Audiology Evaluation (Hearing) Augmentative Communication Evaluation Auditory Brainstem Response Evaluation Central Auditory Processing Evaluation Multi-Therapy Evaluations Dev. Continuity Program(DCP) (MD use only) Wheelchair (Seating) Clinic (MD use only) Hemophilia Clinic (MD use only) Spasticity Clinic (MD use only) OPMS Clinic (MD use only)

Complaint/ Diagnosis

If no referring physician, be sure to obtain an order prior to your appointment.

A written order/prescription from your referring physician is required for all outpatient rehabilitation services. Please, fax order to Rehab CBO at 404-785-7113

Preferred Rehab Location

Children's at Scottish Rite Children's Healthcare at Alpharetta Highway Children's Healthcare at Satellite Boulevard Children's Healthcare at Mount Zion Children's Healthcare of Fayette Children's Healthcare of Cobb Children's Healthcare at North Druid Hills Children's Healthcare at Sandy Plains