Doctor Physical Therapy Referral Form
For usage by both patient and doctor.
Doctors: You may refer a patient to us by printing our referral form and faxing it to our Chicago Office at
Fax: (312) 962-8855 or our Hinsdale office Fax:(630) 850-7537. If you prefer you may print and deliver
signed via patient to Physical Therapy Renaissance.
Prospective Patients: You may print this and bring it to your doctor to facilitate getting a referral for physical
therapy at your next doctor’s visit.
Today’s Date: / /
Patient Name Last: First: Middle:
Evaluation and Initiate Physical Therapy Treatment
Continue Physical Therapy Treatment
Doctor’s Name or Referral Source:
Doctor Phone Number: - -
Doctor Signature: __________________________________________________
Dr. Jennifer Flage Hobson, PT, DPT, MTC, CFC