Referral Form | Pediatric Home HealthCare North Carolina

Looking for a pediatric therapist in North Carolina?

New Client Referral Form

* indicated required fields

First Name

Last Name

Phone

Birthday

Address

Parent / Guardian

What are your concerns?

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

I want services at home.

I want services at the clinic.

I want services at home and clinic

CLINIC INFO

Policy Holder Name (First and Last)

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

Peditrician:

Peditrician location/phone/fax

I hereby affirm that I have only one insurance carrier

Primary Ins Card Front.

Upload File

Upload supported file (Max 15MB)

Primary Ins Card Back.

Upload File

Upload supported file (Max 15MB)

Secondary Ins Card Front.

Upload File

Upload supported file (Max 15MB)

Secondary Ins Card Back.

Upload File

Upload supported file (Max 15MB)

How did you hear about us?

Do you have a perferred Therapist?

Life Touch Therapy would like your consent to send informational text message communications from +18553609433 to your mobile number listed above, in response to your questions or to provide information relevant to your relationship with us.

Consent is not a condition of purchase. Message frequency varies. Message and data rates may apply. Reply 'STOP' to unsubscribe at any time. Reply 'HELP' for assistance or more information. We do not share your mobile opt-in information with anyone. See our privacy policy and messaging terms and conditions available at https://www.lifetouchtherapy.com/ for more information

Yes, I consent to receive informational messages from Life Touch Therapy

You should hear from our referral coordinator within 24-48 hours via text or call. Thank you!

Looking for a pediatric therapist in North Carolina?

New Client Referral Form

Get In Touch