Contact & Referrals

Contact Form

Referrals may be made by contacting us by telephone at 800.561.1392, faxing to 803.396.7814,
or by completing our referral form below.

Referral Source

Company Name

Referral Address

Referral City, State, Zip

Referral E-mail Address

File Number

Employer Name

Employer Phone

Employer Address

Employer City, State, Zip

Employer Contact Name

Industrial Commission File Num

Client / Injured Worker

Client Address

Client City, State, Zip

Client Telephone

Client E-mail Address

Client Date of Birth

Date of Loss

Job Title

Average Weekly Wage

Compensation Amount

Disability

Restrictions

Treating Physician

Physician Address

Physician City, State, Zip

Physician Telephone

Physician Fax Number

Plaintiff Attorney Name

Plaintiff Attorney Firm

Plaintiff Attorney Address

Plaintiff Attny City State Zip

Plaintiff Attny Telephone

Plaintiff Attny Fax Number

Defense Attorney Name

Defense Attorney Firm

Defense Attorney Address

Defense Attny City State Zip

Defense Attny Telephone

Defense Attny Fax Number

Special Instructions

Page Rehabilitation Services, Inc
Post Office Box 855
Fort Mill, SC 29716
Phone | 803.396.7901
Toll Free | 800.561.1392
Fax | 803.396.7814
Email | pagerehab@pagerehab.com

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Contact Information

(800) 561.1392
pagerehab@pagerehab.com
www.pagerehab.com

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Contact & Referrals

Contact Form

Stay Connected

Contact Information