Jefferson University Hospitals

Preparing for Your Visit

Outpatient Intake Form

Please complete the Outpatient Intake Form (PDF) prior to your first appointment with Outpatient Rehabilitation at Jefferson.

Physician Referral Form

If you need outpatient rehabilitation, your healthcare provider needs to provide a referral. In order to make this process easier, bring this therapy slip (PDF) to your physician's office and have them complete and sign it. You can send this to us prior to your first visit so we can begin to coordinate your treatment plan.