Refer a Patient

Your Relationship to Patient

Please complete the following steps to begin the referral process for your loved one:

Complete this form, providing as much of the requested information as possible.
Click “Request Referral” to have your message sent to Shepherd Center’s Admissions Department.
Work with your doctor or case manager to complete the referral process.

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.

Patient's Name

Patient's Date of Birth (DOB)

MM/DD/YYYY

Your Name

Title

Your Phone Number

Your Email Address

Current Patient Location

What facility is the patient in?

City

State or Province

Country

Patient Information

Referring Provider Name

Mailing Address

Email Address

Phone Number

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.