Request a Rehabilitative Services Appointment

Thank you for requesting an appointment for a Physical or Occupational Therapy Evaluation with Northwestern Lake Forest Hospital's Rehabilitative Services Department.

Please complete the fields below and submit. Your request will go to a scheduler who will contact you by phone within one business day during regular business hours, Monday to Friday.

Insurance Information: a physician's referral is required for most therapy services in order for insurance to be billed. However, sports-specific programs that are non-injury related do not require a physician's referral and are not billed to insurance.

Please note: this appointment request is not for emergencies, same day or next day appointments. If you need an appointment within the next 48 hours, or would like to schedule regular ongoing appointments, please contact Central Scheduling at 847.535.8000.

This appointment request form requires you to answer confidential health information that is needed to complete your request and shall be used only for the purpose of helping you secure an office visit. Your personal information will not be shared with any party outside of Northwestern Lake Forest Hospital.

*required information

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Day Phone*

Email*

Gender*

Male
Female

Date of Birth*

What is the best time to contact you by phone to complete your registration?
(Check all that apply.)*

7:00 to 10:00 a.m.
10:00 a.m. to 12:00 p.m.
12:00 to 3:00 p.m.
3:00 to 6:00 p.m.
Other

Are you a new or returning patient?*

New
Returning

Type of appointment:
(Physician referral is required unless otherwise noted.)*

Do you have a physician's order for this appointment?*

Yes, I will bring it to the appointment.
Yes, it has already been faxed by my physician.
No

What type of insurance do you have?

Which day(s) of the week would you prefer your appointment?
(Check all that apply.)*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (morning only)

Which time(s) of the day would you prefer your appointment?
(Check all that apply.)*

7:00 to 9:00 a.m.
9:00 a.m. to 12:00 p.m.
12:00 to 4:00 p.m.
4:00 to 7:00 p.m.
No preference

Which location(s) would you prefer?
(Check all that apply.)*

Lake Forest (Hospital or Health & Fitness Center)
Grayslake

How did you hear about us?*

Additional Questions/Comments

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We offer a variety of appointment times to best fit our patients' busy schedules. Please call to determine the best appointment time for you.

Rehabilitative Services

Lake Forest
847.535.6520

Grayslake
847.535.8833