Refer a Patient

Appointments are available now. Please fill out the form below or place one convenient call to our Rehabilitation Solutions Call Center: 1 (800) 44-REHAB (73422) or (713) 797-5942.

The information collected in this form will be used to coordinate rehabilitation services for your patient. The Rehabilitation Solutions Call Center schedules appointments for inpatient rehabilitation, outpatient medical clinic and outpatient rehabilitation.

Start the Process

5 Minute Form This form will take 5 minutes to complete.

TIRR Memorial Hermann accepts most insurance.

We will respond within the next business day.

Fields with an asterisk (*) are required.

Looking to refer someone you know?

This form is intended to be used for physicians and health care professionals referring patients to TIRR Memorial Hermann. If you are an individual, family member, friend or caregiver, please click the button below to submit a Become a Patient form.

Become a Patient

Patient Information

Patient First Name: *

Patient Last Name: *

Email Address: *

Phone Number: *

Date of Birth:

Referring Information

Referring Physician's Full Name: *

Referring Physician's Email Address: *

Referring Physician's Phone Number: *

Facility & Case Details

Referring Facility Name: *

Case Type *

Level of Care *

What type of visit? *

How did you hear about TIRR Memorial Hermann?

Thank
You!

We have received your request to join the TIRR Refer a Patient. A team member will contact you shortly.

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Refer a Patient

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Patient Information

Referring Information

Facility & Case Details

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