Become a Patient

Comprehensive System of Care

Rehabilitation Hospital or Skilled Nursing Care

Around-the-clock care supported by our team of physicians, nurses and therapists.

Outpatient Therapy

Visit one of our award-winning centers in North Florida, Daytona, or Orlando for a physical, occupational or speech therapy consultation.

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Home Health

Receive support from highly-trained nurses and therapists—all from the comfort of your home.

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Custom Care at Home

In-home private duty care that provides daily living assistance, companionship and respite services for both short-term and long-term treatment plans.

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Become a Patient

To request more information about becoming a patient, fill out this form and a member of the Brooks team will be in touch soon.

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Patient Information

Name*

First Last

D.O.B.*

Gender*

Type of Care Needed*

Patient's Current Location*

Name of Hospital or Care Facility Patient is Currently At*

City*

State*

Please Explain*

Diagnosis/Appointment Information

New Patient*

Diagnosis Type*

Appointment Type Needed*

Home Health Care Needed*

Please Provide More Details*

Please Explain Patient's Condition/Needs

Referring Physician Information (if available)

Physician's Name

Physician's Email

Physician's Phone

Insurance Information

Insurance*

Please Explain*

Please Specify*

Primary Contact Information

Primary Contact's Name*

First Last

Primary Contact's Email*

Primary Contact's Phone*

Relationship to Patient*

How Did You Hear About Us?*

Please Explain*

Let us join you on the road to recovery

Comprehensive System of Care

Rehabilitation Hospital or Skilled Nursing Care

Outpatient Therapy

Home Health

Custom Care at Home

Become a Patient

Patient Information

Diagnosis/Appointment Information

Referring Physician Information (if available)

Insurance Information

Primary Contact Information