Referral Forms

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In the state of Texas, patients are able to seek physical therapy services without a referral. However, if the patient decides to continue physical therapy services beyond ten business days, a referral is required. Referrals are accepted from providers including physicians, chiropractors, APRNs, and physician assistants. Below are referrals for each professional; you are welcome to print a referral form to take with you to your appointment. Once signed, the referral can be faxed to Texas Pelvic Health, or you are welcome to bring it to your appointment and it will be loaded into your chart.

Physician Referral Form

chiropractor referral form

Physician’s Assistant Referral Form

APRN Referral Form

Referral Forms

If you are a provider and would like referral pads, I would love to deliver them to your office.

Please contact here.

Texas Pelvic Health