For Healthcare Providers

Refer a Patient to IPC

Submit a secure referral for patients who may benefit from specialty integumentary rehabilitation — including lymphedema management, oncology rehabilitation, wound care, and ostomy support.

Submit Referral Securely Download Referral Form (PDF) (321) 972-3238

A specialty program of the Integumentary Physiotherapy Institute

Referral Fax
(321) 972-3590

Referrals received by fax are processed within 24 business hours. Attach clinical notes and diagnosis documentation when available.

Referral Fax
(321) 972-3590
Submit Referral Securely Download Referral Form (PDF)
Referral Options

Choose a Referral Method

Use the online intake when available, or send the completed referral form by fax.

Submit Referral Securely Complete the configured Gravity Forms referral intake.
Download Referral Form PDF Use the printable fallback when online intake is unavailable.
Referral Fax (321) 972-3590
Clinical Eligibility

When to Refer to IPC

IPC specializes in post-surgical, oncologic, and integumentary rehabilitation. The following presentations are appropriate for evaluation referral.

Lymphedema After Cancer Surgery

Patients presenting with unilateral or bilateral limb swelling following lymph node dissection, sentinel node biopsy, or other oncologic surgery. Includes breast, gynecologic, urologic, head and neck, and melanoma-related procedures.

Oncology Rehabilitation

Patients experiencing cancer treatment–related functional decline, fatigue, deconditioning, chemotherapy-induced peripheral neuropathy, or post-mastectomy syndrome requiring structured therapeutic rehabilitation.

Non-Healing Wounds

Chronic wounds that have not responded to standard wound care — including venous stasis ulcers, diabetic foot ulcers, pressure injuries, arterial ulcers, and post-surgical wounds with delayed healing.

Radiation Fibrosis

Soft tissue and skin changes following radiation therapy — including subcutaneous fibrosis, restricted range of motion, trismus, breast radiation sequelae, and chronic inflammatory changes in the treatment field.

Post-Surgical Swelling

Persistent edema, seroma formation, or swelling following orthopedic, reconstructive, bariatric, or general surgical procedures that has not resolved with standard post-operative management.

Ostomy Rehabilitation Needs

Patients post-colostomy, ileostomy, or urostomy who require functional rehabilitation, peristomal skin management, core stabilization, and integration of ostomy self-care into daily function.

Secure Submission

Submit Referral Securely

Complete the provider referral intake through the configured Gravity Form. Clinic notification, storage, and routing policies must be finalized before production use.

This secure referral form is appropriate for non-urgent referrals only. For urgent clinical coordination, please call our provider line at (321) 972-3238.
This field is for validation purposes and should be left unchanged.

SECTION 1 — Referring Provider

Use a direct clinical contact when available. Standard email notifications should not contain PHI.
Direct office line or extension if needed.
Preferred contact method

    • SECTION 2 — Patient Information

    Enter date as MM/DD/YYYY
    MM slash DD slash YYYY
    Optional. Use the best callback number if available.
    Preferred contact method

    • SECTION 3 — Referral Request

    Requested service*
    • Urgency
    • Has patient been informed of referral?

    • SECTION 4 — Documents

    Upload only the documents IPC needs for clinical review and intake coordination.
    Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 300 MB.
    Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 300 MB.
    Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 300 MB.
    Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 300 MB.

    SECTION 5 — Coordination Notes

    Fax & Fallback Options

    Prefer to Fax?

    Download the IPC referral form, complete it, and send via fax. Referrals received by fax are processed within 24 business hours. Attach clinical notes and relevant diagnostic documents.

    Referral Fax:  (321) 972-3590 Clinic Phone:  (321) 972-3238
    Download Referral Form (PDF) (321) 972-3238

    Questions About a Referral?

    Call the clinic directly — our team is available to assist with referral coordination, eligibility questions, and scheduling.

    Request Evaluation

    Or call (321) 972-3238 — Mon–Thu 9AM–4PM · Fri 9AM–1PM

    A specialty program of the Integumentary Physiotherapy Institute