Online Referral Form

Complete and submit the form below — and a practicing therapist/Advantage OT clinic director at the Advantage OT clinic of your choice will contact you to arrange treatment.

Patient Information:

Patients First Name:*

Patients Last Name:*

Diagnosis:

Patients Phone:*

Patients Email:

Street Address:

City:

Zip Code:

Treatment Type: *

Functional Capacity Evaluation (FCE)

Work Conditioning Program (WCP)

Functional Home Living Assesment

OTHER

Physician Prescription:*

Yes

No

Referring Physician, Case Manager or Adjuster Information:

You are a:*

Physician Case worker Adjuster Other

Referring Parties
First Name:*

Referring Parties
Last Name:*

Referring Parties Title:*

Organization:*

Physician Email:*

Physician Phone:*

Insurance Information:

Workers Comp

Auto (Primary)

Insurance Co:

Adjuster:

Claim Number:

Phone:

Choose a Clinic Location: *

Mt. Clemens

Wayne

Wixom

Submit

Download Prescription Form