This is a form for referring your patient to NIPMR for comprehensive multi-disciplinary rehabilitation. The rehabilitation team would assess individual referrals and make a priority list based on the patient condition, prognosis and rehabilitation potential. The information you provide will help in more informed decision making and hence it is requested to provide the most accurate information known to you. The NIPMR team would decide whether to admit the patient for inpatient rehabilitation, or for outpatient therapy. Either ways, the rehabilitation team might physically or through telehealth would assess the patient and make decisions about admission. The team reserves the right to admit and discharge patients, based on the protocol set and no external pressure whatsoever will be entertained in this clinical decision making process. The number of beds is limited and it will be our effort to benefit maximum number of patients through effective triage, categorising patients to intense/fast stream versus slow stream rehab and offering outpatient therapy.

To be filled by the Referring Institutions or Clinicians

Client/Patient Details: