IMG_2948_2Who may refer patients?

“The things you do for yourself are gone when you are gone, but the things you do for others remain as your legacy.”― Kalu Ndukwe Kalu

How to refer patients

  • Providers may fax referrals directly to our clinic and we will call patients to schedule

  • Providers may call our clinic to schedule directly.

  • Providers can provide a referral to patients and the patient can then contact us to schedule at their convenience.

  • For your convenience, you may download our referral form for use in your office.  You can also fill out the form online in tab above Provider referral form

  • We are also happy to provide you with Success Physical Therapy prescription pads if you prefer; simply contact our office

    Today's Date

    Date of Birth

    First Name

    Last Name



    Patient Address (required)

    Address Line 2



    Zip Code


    Treatment Order

    Evaluate and Treat



    or Per Therapist Discretion


    Click N/A if no options apply in each section below

    General (required)

    Urinary/ Bowel Incontinence/Voiding Dysfunction (required)

    Pain (required)

    Pelvic Organ Prolapse (required)

    Physician Name

    Physician ID Number

    Physician Signature




    Success Physical Therapy 850 N. Kolb Road. Tucson, AZ 85710 Ph.: 520-885-5125 Fax: 520-885-5126

    Contact us

    • 520-885-5125, fax 520-885-5126
    • Our goal is to maintain direct, timely communicate with our providers to allow integrated care.  Please contact us with any questions or feedback regarding mutual patient care.

    Physical Therapy Services

    • Excellence in customer service.

    • Comprehensive physical therapy services designed to decrease pain and restore normal function. Manual therapy, exercise instruction, neuromuscular retraining, and extensive patient education.

    • Posture and biomechanics evaluation and treatment.

    • Biofeedback for retraining of pelvic musculature as adjuncts to other treatment methods.  

    • Individualized patient care according to his or her needs; treatment is adjusted accordingly at each visit.

    • New patient evaluation is 60-90 minutes.

    • Follow-up treatment sessions are scheduled for 60 minutes and are provided solely by a physical therapist.


    • Success Physical Therapy has chosen to be a fee-for-service based practice and operates as an out-of- network provider of physical therapy services.

    • We have chosen not to establish contracts with any insurance companies because we believe in providing physical therapy services according to individual need, rather than based on insurance benefits.

    • We do not have to limit the time or quality of treatment provided because of insurance company restrictions, or elevate our rates to pay for billing services.

    • Additionally, we have the flexibility to assist patients in financial need.

    • Each patient will be issued an insurance billing form for submission to his or her insurance carrier.