Patient Referral Forms

If you are a healthcare professional or clinician (such as a representative from a physician practice, insurance provider, employer or a health plan case manager) referring a new patient for treatment, please fill out the relevant Patient Referral Forms and fax them to 317-706-3417.

NOTE: Our office must receive the patient’s medical records from a current physician PRIOR to the patient’s appointment.


Adobe-PDF-icon New Patient Referral Form


Adobe-PDF-icon Physical Therapy Patient Referral Form


Adobe-PDF-icon MRI Procedure Referral Form

Refer a Patient
This form is for health care professionals to refer patients. Medical records from current physician must be received prior to appointment.
  • Referring Office Contact Info

  • Patient or Case Information

  • This field is for validation purposes and should be left unchanged.