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 *Occupational TherapyPhysical TherapySpeech TherapyAquatic TherapyDynamic Movement Intervention (DMI)Feeding TherapyInfant MassageDo 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
