On-Line Referral

Please complete all sections. We will contact you by phone within two business days to schedule your appointment or to review your case. Thank you for your interest in IOHS. We look forward to caring for your occupational therapy needs! If you would prefer to print and deliver this form, you can download a copy here.

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Client Name(*)

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Email Address(*)

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Address

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Telephone #(*)

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Referring Agent

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Agency

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Agency #

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Billing Agent

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Date of Injury

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Claim #

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Treating Physician

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Diagnosis

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Date Last Worked

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Is the client medically cleared to return to work?

Yes No Invalid Input

Are there any medical restrictions? (Specify)

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Pre-injury Employer

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Contact Person

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Occupation

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Employer Telephone

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Is the client’s pre-injury employment available?

Yes No Invalid Input

If not, is alternate employment available?

Yes No Invalid Input

What questions do you want answered from this referral?

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Services

Other Services

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Please add any additional information you feel is of benefit:

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Thank you. By completing this form, you have allowed us to process your request as quickly as possible. Please click the "Submit" button below, and remember when you come to your initial appoint, to please bring with you all recent medical documentation.

Recaptcha(*)

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Referral Form

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