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.

Learn More

Home Health

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

Learn More

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.

Learn More

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.

"*" indicates required fields

Patient Information

Name*

First Last

D.O.B.*

Type of Care Needed*

Patient's Location*

Which Hospital or Care Facility?*

Home Location*

Please Explain*

Patient Status*

Appointment Type*

Please Explain Patient's Condition/Needs

Referring Physician Information (if available)

Physician's Name

Physician's Email

Physician's Phone

Additional Details

Insurance

Please Specify

Primary Contact Information

Primary Contact's Name*

First Last

Primary Contact's Email*

Primary Contact's Phone*

Relationship to Patient (if different than the 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

Referring Physician Information (if available)

Additional Details

Primary Contact Information