NCH Outpatient Rehab Services
Make an Outpatient Rehabilitation Appointment
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As a convenience to our patients, you may complete this form in order to schedule your Physical, Occupational, or Speech Therapy. Enter your information in the fields below, then click the "Submit Request" button at the bottom of the page.

Your Name:
 
Your Email Address:
 
Birth Date:
Address 1:
Address 2:
City, State, Zip:
Telephone Number:
Best time of day to reach you:
Do you have a prescription from your doctor?  
Your Doctor's Name:
Doctor's Phone Number:
Diagnosis:
Select Facility:
Name of Insurance::
Insurance Number:
Please indicate up to 3 preferred appointment days and times:



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NCH Outpatient Rehabilitation Centers

Briggs Pavilion:

(239) 624-1600

Green Tree Plaza:
(239) 596-0834

Bonita Center:
(239) 947-4440

Marco:
(239) 393-4079

Immokalee:
(239) 657-2228