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

top of page

Asset 2_300x.png

Home
Clinic
- Hand Writing Camp
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)

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