Refer a Patient

Please complete the form below, providing as much of the requested information as possible. When finished, click on "Request Referral" to have your message sent to Shepherd Center's Admissions Department.

Your Relationship to Patient

Injury Type

If other, please describe

Rehabilitation Type

Has a case manager or other healthcare professional submitted a referral for the patient to receive treatment at Shepherd Center?

Please have your case manager or other healthcare professional fax a formal referral submission to Shepherd Center at 404-603-4504.

Referral Information

Patient's Name

Patient's Date of Birth (DOB)

MM/DD/YYYY

Your Information

Your Name

Title

Your Phone Number

Your Email Address

Patient Status

Current Patient Location

What facility is the patient in?

City

State or Province

Country

Patient Information

Referring Provider

Referring Provider Name

Mailing Address

Email Address

Phone Number

Additional Information

Insurance

How did you hear about Shepherd Center?

Please fax the patient’s medical records to Shepherd Center at 404-603-4504.

Download this PDF file to get a checklist of additional information needed for the referral process.

Refer a Patient

Referral Information

Your Information

Patient Status

Referring Provider

Additional Information

Resources on Choosing a Rehabilitation Facility

In this section

Admissions