Make Rehabilitation Appointment

Patient's Name *

First

Last

Patient's Birthdate *

Is this appointment for you? *

YES
NO

Your Name *

First

Last

Your Relationship to Patient *

Please Specify If Other *

Phone *

Email *

Preferred Contact *

EMAIL
PHONE

Preferred Appointment Date *

Date

Time

Pending confirmation from JRMC.

Which Service *

Preferred Audiology Location *

Preferred Orthopedic Location *

Preferred Podiatry Location *

Preferred Orthopedic Provider *

Preferred Podiatrist / Foot & Ankle Surgeon *

Dr. Rachael Renschler
Dr. Kayla Emter
First Available

Preferred Physical Therapist *

Preferred Occupational Therapist *

Sarah Redding, OTR/L
Leann Ripplinger, OTR/L
Amy Walz, OTR/L
First Available

Preferred Wound Specialist *

Amanda Lausch, APRN, FNP-BC
Holli Marquart, APRN, CNP
Dr. Kayla Emter
First Available

Is this a "No Excuses" request? *

YES
NO

"No Excuses" offers pap smears and mammograms to reduce barriers to women’s care.

JRMC's Audiologist is Marissa M. Leese, AuD.

Dr. Michael T. Dean cares for orthopedic patients at our Carrington Clinic.

Dr. Timothy Volk cares for orthopedic patients at our Valley City Clinic.

Dr. Rachael Renschler cares for podiatry patients at our Carrington Clinic.

JRMC's Ear, Nose & Throat specialist is Dr. Steven Cox.

JRMC's Gynecologist is Dr. Gregg McAdoo.

JRMC's Urologist is Dr. Christopher Cost.

JRMC's Speech Therapist is Lauren Burningham, MS, CCC-SLP.

Briefly Indicate Reason for Appointment *

Do you have medical insurance? *

YES
NO

Primary Insurance *

Any Other Forms of Insurance

Would you like a patient financial advocate to contact you regarding what insurance options are available? *

YES
NO

Financial Responsibility *

I acknowledge that it is my responsibility to verify insurance authorization or coverage when self-referring for an appointment.

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