Referral Form | Pediatric Home HealthCare North Carolina | Life Touch Therapy

top of page

Asset 2_300x.png

Home
Clinic
Referral Form
Family and Patients
- Consent for Treatment Form
Healthcare Providers
Contact Us
- Payments Here
About Us
Blog
Events
More

Use tab to navigate through the menu items.

Looking for a pediatric therapist in North Carolina?

New Client Referral Form

* indicated required fields

First Name

Last Name

Email

Phone

Birthday

Address

Parent / Guardian

What are your concerns?

Location of Services: Please check which location you prefer for services. *

I want services a home.

I want services at the clinic.

Policy Holder Name (First and Last)

Policy Holder Date of Birth (month/day/year)

Insurance Card Front

Upload File

Upload supported file (Max 15MB)

Insurance Card Back

Upload File

Upload supported file (Max 15MB)

How did you hear about us?

Thanks for submitting!

Contact Us

Telephone: +1 (855) 360-9433

Fax: 704-793-6308

Email: info@lifetouchtherapy.com

© 2019 by Smitty Ink, LLC and Life Touch Therapy, LLCP

bottom of page