Physical therapy referral form
A physical therapy referral form is filled out by a referring physician (MD, DO, NP) sending a patient to a PT clinic. It includes the patient's diagnosis, the recommended number of sessions, and any precautions — so the PT can plan the treatment course immediately.
The form beside this text is live. Fill it in and submit it — it validates exactly as it would for a real respondent, and saves nothing.
A precautions field lets the physician flag what NOT to do
Post-surgery patients or those with recent fractures need movement restrictions documented before the PT session starts.
Session recommendation helps the clinic plan the care plan
The physician can suggest 6–12 visits, and the PT knows the expected scope upfront.
No card required.
Physical Therapy Referral Form
Live previewHow to build this form
5 steps in the editor. Nothing here needs a paid plan.
- Add text and email fields for the referring physician's name and contact information.
- Add text and date fields for the patient's name and date of birth.
- Add a textarea for the diagnosis or reason for referral.
- Add an optional number field for recommended session count.
- Add an optional textarea for precautions or movement restrictions.
Fields in this form
8 fields, using 6 of the 19 field types available.
| Question | Field type | Required |
|---|---|---|
| Referring physician name | Short text | Yes |
| Physician email | Yes | |
| Physician phone | Phone | Yes |
| Patient name | Short text | Yes |
| Patient date of birth | Date | Yes |
| Diagnosis or reason for referral | Long text | Yes |
| Recommended number of sessions (optional) | Number | Optional |
| Precautions or movement restrictions (optional) | Long text | Optional |
What goes wrong with this form
Specific to a physical therapy referral form, not general advice about forms.
Not asking for physician license or NPI number
The clinic may want to verify the referrer is licensed. Add an optional field for NPI or medical license number.
Forgetting to ask for precautions or movement restrictions
A post-operative patient needs clear direction on what movements are off-limits — omitting this field risks patient re-injury.
Using a dropdown for diagnosis instead of a textarea
Diagnoses are too varied to list in a dropdown. Use a textarea so the physician can write the exact clinical picture.
Questions about this form
Does this form verify the physician's credentials?
No. The form collects who submitted it; the clinic should verify licensure independently. Treat this like a reference form — it captures what was submitted.
Can I add insurance information fields?
Yes. Add text fields for insurance carrier, policy number, and group number so the clinic can verify coverage before the patient's first visit.
What if the referral is for prevention or wellness, not an injury?
That's valid. The diagnosis field can say "Wellness", "Posture assessment", or "Fall prevention".
Other templates
- Patient intake formInsurance provider and ID as their own fields, so registering doesn't start with a phone call.
- Medical HistoryCollect a new patient's medical background before the first appointment.
- Insurance VerificationCollect insurance details before the appointment so staff can verify coverage manually.