Specialty Program InquiryPlease fill out this form is you are interested in one of our specialty programs. If your need is urgent, please call our office at 619.578.2232. We look forward to working with you. Please enable JavaScript in your browser to complete this form.Name of Child *FirstLastName of Parent or Guardian *FirstLastPhone Number *Email *What Service(s) Are you Interested In *Aquatic TherapyDynamic Movement Intervention (DMI)Feeding TherapyInfant MassagePROMTDo You Have A Referral For Service(s)? *Yes: I have oneYes: the referring provider has faxed it to MilestoneNo: I will reach out to the referring providerIf you have a referral for service please fax to 619.578.2231, email to scheduling@milestoneclinic.com, or drop off at our clinic. If you do not have a referral for services, please contact your referring provider to have them fax the referral to Milestone. What Insurance or Payment Method Will You Be Using To Cover Services? *Kaiser PermanentePrivate PaySan Diego Regional CenterScripps HealthSuperbill for Out-of-Network InsuranceTricareOtherOur in-network insurances are always changing so please call our office to find out if we accept your insurance. Referring Provider Who Will Be Sending The Referral *FirstLastReferring Provider Office Name *Referring Provider Phone Number *Referring Provider Fax Number *Submit
