Patient Referral

Please use the form below to refer a patient to Mountain Land. If you have any questions, please contact us at 1-800-574-4792 x176 or email us at outpatientsupport@mlrehab.com.

Referrer Name

Referrer Email

Law Firm/Attorney Name

Client Name

Client Phone Number

What clinic would the client like to attend therapy at?

Is the injury from an auto accident?
YesNo

Please provide any additional information: