Referrals

Please fill in the fields below to refer a patient to Better Yourself Rehab. Other than the file field, all fields are required. If you have any questions, please call us at 646-470-8615 or send an email. Fields with an * are required.

212-123-4567
212-123-4567
123456789A
Use this field to upload any necessary files, such as prescriptions.
Let us know of any general or specific instructions regarding your patient.
CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.