Referring Patient to Orlando City Health and Wellness

Referring to Orlando City Health and Wellness for:

Physical Therapy

Chiropractic

Massage Therapy

Auto Accident Evaluation & Treatment

Sports Physical

Shcokwave Therapy

DOT (Department of Transportation) Exam

Slip & Fall Treatment

Other

Referring Provider Office Information

Referring Provider / Doctors office:

Do you want the records emailed or faxed to your office?

Email
Fax
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Fax:

Email to send records to:

Below you can type any relevant clinical information:

If you can attach relevant clinical information, initial examination, MRI findings, including your patient intakes, patient insurance, and patient ID we greatly appreciate it. If not, we understand.

You can upload documents here

Patient Information

Patient Full Name

Phone Number:

Date of Birth (MO/DD/YYYY)

What best describes your gender?

Female

Male

Non-binary

A gender not listed here

Prefer not to say

Best Describes your Gender?

Male
Female
Non-Binary
A Gender Not Listed
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Address

City

State

Postal code

Phone *

Patient's email

Patient Insurance Information

Name of Insurance

Insurance Policy #

Group #

Attorney Information if Applicable

Law office

Phone number

Auto Insurance Information if Applicable

Name of patients auto insurance

Patient's claim number

What state did the accident occur in?

The date of the accident / Date of Loss

Alchemist Connect LLC