Referral Form

Referral Form

Work-Comp Referral Form:

This form is to be completed by case managers, insurance adjusters, RN nurses and/or Doctors. Please fill out the required fields and a member of our staff will be in contact with you shortly. Thank you for your referral to Aquatic Fitness, Inc.

For a printable version of this form, please click here.





Your Email (required)

Patient Information

Patient Name(required)

Patient Address(required)

Patient Phone Number(required)

Patient Work or Cell Number

Patient DOB (required)

Patient DOI (required)

Patient SSN (optional)

Employer Information

Employer Name(required)

Insurance Information

Claims Rep Name(required)

Claims Rep Company Name(required)

Claims Rep Address(required)

Claims Rep Phone Number(required)

Claims Rep Fax Number(required)

Claim Number

Rehab Company Information

Case Manager Name

Case Manager Company Name

Case Manager Phone Number

Case Manager Fax Number

Physician Information

Doctor Name(required)

Doctor Address

Doctor Phone Number

Doctor Fax Number

Diagnosis

Frequency

Please Choose A Location

Location
 Creve Coeur Clinic O'Fallon Clinic Either

Please Upload Prescription or Other Information

Additional Notes

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