Appointment Form - Rehabilitation Institute of Chicago

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For fastest service, please call toll-free 1-800-354-REHAB (7348) or 1-312-238-1000 locally.

Patient Appointment Request

* Denotes required fields

Patient's Personal Information

* Gender
* Resident of Illinois or Local Indiana (Porter/Lake County)
* Who is making the appointment request?
What type of appointment are you requesting today?

Patient Condition Information

* Is the patient currently receiving rehabilitation care?
* How would you prefer to be contacted?

What are your preferred contact dates and times?

When we contact you, will you require that we communicate with you in a language other than English?

If you experience any issues or have any corrections, comments, or concerns, please contact