---
title: Chiropractic to Physical Therapy Referral Form Template | Paperform
description: Streamline specialist referrals with this comprehensive chiropractic to PT referral form. Includes injury assessment, treatment history, mobility limitations, and insurance verification.
url: "https://paperform.co/templates/chiropractic-to-physical-therapy-referral-form"
type: static
generatedAt: "2026-03-28T00:43:18.715Z"
---

[← Back to free form templates](/templates/)    ![Chiropractic to Physical Therapy Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/chiropractic-to-physical-therapy-referral-form.png)
    [Preview](https://_preview.paperform.co/ai-template/chiropractic-to-physical-therapy-referral-form) [Use this template for free](/create?ai-template=chiropractic-to-physical-therapy-referral-form)    [Healthcare & Medical Forms](/templates/category/healthcare/) [Healthcare](/templates/industry/healthcare/)[Chiropractic & Alternative Medicine](/templates/industry/chiropractic/) [Physician](/templates/role/physician/)[Chiropractor](/templates/role/chiropractor/)[Physical Therapist](/templates/role/physical-therapist/)[Healthcare Administrator](/templates/role/healthcare-admin/)     About this free form template
### Streamline Your Chiropractic to Physical Therapy Referrals

When a chiropractic patient needs specialized physical therapy intervention, a smooth and detailed referral process ensures continuity of care and better patient outcomes. This **Chiropractic to Physical Therapy Referral Form** template is designed specifically for chiropractors, sports medicine clinics, and integrated healthcare practices that regularly coordinate care between disciplines.

#### Why This Template Matters for Your Practice

Manual referral processes—faxing handwritten forms, incomplete patient histories, missing insurance details—create unnecessary friction that delays treatment and frustrates both providers and patients. This Paperform template replaces outdated workflows with a streamlined, professional digital referral system that captures everything the receiving physical therapist needs in one submission.

The form collects comprehensive injury assessment details, complete treatment history from your chiropractic care, specific mobility limitations and functional deficits, and upfront insurance verification—all the information required for the PT to create an effective treatment plan from day one. No more follow-up calls to clarify details or track down missing documentation.

#### Built for Chiropractic and Integrated Healthcare Practices

This template is ideal for:

 - **Chiropractic clinics** that regularly refer patients requiring advanced therapeutic exercise, post-surgical rehabilitation, or specialized modalities beyond chiropractic scope
 - **Sports medicine practices** coordinating multi-disciplinary care for athletic injuries
 - **Integrated wellness centers** with both chiropractic and physical therapy services who need formal internal referral documentation
 - **Hospital-affiliated chiropractors** following formal referral protocols for insurance and continuity of care
 - **Network providers** maintaining professional referral relationships with trusted physical therapy partners

#### What Makes This Referral Form Comprehensive

The template captures all essential referral information in a logical flow:

**Patient and Provider Information:** Complete demographics, contact details, referring chiropractor information, and preferred physical therapy provider **Injury Assessment:** Detailed documentation of the primary complaint, injury mechanism, onset date, pain characteristics, and affected body regions **Treatment History:** Comprehensive record of chiropractic interventions provided, treatment frequency, patient response, and clinical progress **Mobility and Functional Limitations:** Specific documentation of range of motion restrictions, functional deficits, activities of daily living impacts, and work/sport limitations **Clinical Findings:** Space for relevant examination findings, diagnostic imaging results, and contraindications the PT should know **Insurance Verification:** Upfront capture of insurance details, authorization numbers, and coverage verification to prevent billing delays

#### Enhance Your Referral Workflow with Automation

Once you've customized this template to match your practice protocols, Paperform's automation capabilities ensure every referral moves smoothly through your system:

**Instant Notifications:** Send automatic confirmation emails to both the patient and receiving physical therapy practice the moment a referral is submitted, so everyone knows the handoff is in motion.

**Professional Documentation:** Generate a clean, professional PDF of the referral that can be automatically sent to the PT practice, stored in your practice management system, or attached to the patient record.

**Integration with Your EHR:** Connect submissions to your practice management software or EHR via [Stepper](https://stepper.io) workflows—no manual data entry required. Stepper can route referral data to systems like Jane, Cliniko, or your custom database, keeping all patient information synchronized.

**Insurance Follow-Up Automation:** Set up workflows that track whether insurance authorization has been obtained and trigger follow-up tasks if verification is pending, ensuring billing issues don't delay patient care.

**Referral Tracking Dashboard:** Push submission data to Airtable or Google Sheets to maintain a live referral tracking system, monitoring which PTs you refer to most often, referral outcomes, and partnership effectiveness.

#### Professional, Branded and Compliant

This form is SOC 2 Type II compliant and includes robust security features to protect patient health information. While Paperform is not HIPAA compliant, it provides enterprise-grade security suitable for many healthcare workflows outside of strict HIPAA requirements.

Customize the form's appearance to match your practice branding—add your logo, adjust colors to your brand palette, and include your clinic's professional imagery. The clean, easy-to-complete design ensures busy healthcare providers can submit thorough referrals in just a few minutes.

#### Get Started in Minutes

This template includes all the fields and logic you need right out of the box. Simply customize the referring provider dropdown to your practice, adjust any clinical terminology to match your documentation style, and connect your preferred notification and integration workflows. You'll have a professional referral system running the same day.

Whether you're a solo chiropractor building referral relationships or a multi-provider integrated practice coordinating complex care, this template gives you the foundation for seamless, professional patient handoffs that improve outcomes and strengthen provider partnerships.

Trusted by healthcare providers who need efficient, detailed clinical referral forms, this Paperform template is your starting point for better coordinated care.
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