First Name
Last Name
Therapy Company
Would you like to coordinate a home visit and would you like to be present?
Do you have a RX on file?
Please fax to our office the following:
(1) Physician's prescription
(2) Patient Face Sheet
(3) Most recent patient clinical note including therapy goals

FAX (214) 819-8047

NOTE: Patients must have a current prescription with diagnosis from the referring Physician to be evaluated.
Please complete information to the right with the your information.