Patient Care Request

This form is intended for patients who would like to request

in-home rehabilitative therapy services.

If you are a home health agency representative or a physician referring a patient - please click this link:

https://www.ultratherapysolutions.com/refer-a-patient

Name*

Are you located within our service area in Texas, which includes the DFW and surrounding regions?*

(Click here to view our service coverage area)

Yes

Phone number*

Phone

Email address*

Best way to contact you*

Call

Text

DATA PRIVACY STATEMENT

By submitting this form, I acknowledge that I have read and agree to the Ultra Therapy Solutions Privacy Policy. I understand that my personal information, including my name, email address, and phone number, will be used solely for the purpose of processing my care request in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Ultra Therapy Solutions takes all necessary steps to ensure that my data is securely stored and will not be shared with any unauthorized third parties.

I consent to collecting, storing, and using my data as described in the privacy policy and agree to be contacted by UTS for follow-up regarding my request.

I ACKNOWLEDGE*

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Yes

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