Physician Referral Form

Thank you for trusting us with your patients. Our licensed physical therapists specialize in orthopedic, neurological, and post-surgical rehabilitation. Complete the form below and our team will contact the patient within one business day to schedule their evaluation.

Ridgewood, Queens Forest Hills, Queens

Referring Provider

Provider / Physician Name*

Practice / Office Name

Provider Phone*

Provider Fax

Provider Email*

Patient Information

First Name*

Last Name*

Date of Birth*

Patient Phone*

Insurance / Health Plan

Referral Details

Diagnosis / Reason for Referral*

ICD-10 Code(s)

Preferred Location*

Additional Notes

Authorization

I confirm that I am authorized to share this patient’s health information with Sunnyvale Physical Therapy for the purposes of scheduling physical therapy services, and that the patient has been informed of this referral.

Questions? Contact Us

Our clinical team is happy to discuss cases before submitting a referral.

Ridgewood

(718) 400-7500

Forest Hills

(718) 275-4700

Why Refer to Sunnyvale PT?

✓Licensed & experienced PTs
✓Orthopedic, neuro & sports rehab
✓No-fault, WCB & most major insurances
✓Two convenient Queens locations
✓Prompt scheduling — often same week
✓Progress reports sent to referring provider

Clinical Hours

Monday – Friday8:00 AM – 8:00 PM

Saturday8:00 AM – 1:00 PM

SundayClosed

Send a Referral