Phone: (702) 577-1962
Fax: (702) 577-1956
Phone: (918) 932-2787
Fax: (918) 884-7708
Patient's Name *
Patient Phone Number *
Patient Date of Birth *
Referred By *
Date of Injury
Primary Language Spoken
Preferred Treatment Location * Las Vegas - NorthwestLas Vegas - Green ValleyLas Vegas - CentralLas Vegas - SunsetLas Vegas - CharlestonLas Vegas - NortheastLas Vegas - Southwest
Please complete and submit this form to refer your auto accident and personal injury patients to Core Rehab.
