The information collected in this form will be used to coordinate rehabilitation services for you or a loved one. The Rehabilitation Solutions Call Center schedules appointments for inpatient rehabilitation, outpatient medical clinic and outpatient rehabilitation.
This form will take 5 minutes to complete.
TIRR Memorial Hermann accepts most insurance.
We will respond within the next business day.
Fields with an asterisk (*) are required.
Looking to refer a patient?
This form is intended to be used by individuals, family members, friends or caregivers looking to become a patient or help someone become a patient of TIRR Memorial Hermann. If you are a health care professional looking to refer your patient, please submit our Refer a Patient form.
For the 31st consecutive year, TIRR Memorial Hermann is recognized as the best rehabilitation hospital in Texas and No. 3 in the nation according to U.S. News and World Report's "Best Rehabilitation Hospitals" in America.Learn More