Patient Referral Form

Patient Referral Form

Click on the Referral Form button below to access the patient referral form or prescription for physical therapy form to complete for your convenience. Please complete and return the patient referral form or prescription for physical therapy form and fax them to (334) 649-1010. Once we receive the patient referral form or prescription for physical therapy form, then your patient will be contacted to schedule an appointment for an initial evaluation. Please note: The patient's medical diagnosis, history, physical, and demographics in addition to the ICD-10 code must be included on the patient's referral form or prescription for physical therapy form. If you need assistance or have any questions, please contact us at (334) 549-4231 or email us at DovePhysicalTherapy@gmail.com or OA@dovept.com.