Transfer a Patient to Luna

Submit a prescription

Submit an Rx securely for your patient using the form below. We’ll use this information to contact and onboard your patient to Luna.

First Name*

Last Name*

Phone*

Email*

Gender

DOB

Pets in the Home?

Home-health?

Address*

City*

Zip*

Arrival Instructions (Parking, Gates, Stairs, Etc.)

Reason for Treatment

Therapist Request If the patient would like to see their existing therapist for in-home PT, please list the therapist’s name here.

Date of Surgery

Desired Date to Begin PT

Duration

Frequency

Primary Insurance*

Policy Number

Other (Name of Policy Holder / Relation to Self / Address if Different Than Patient, Etc.)

Secondary Insurance

Policy Number

Other (Name of Policy Holder / Relation to Self / Address if Different Than Patient, Etc.)

Form Submitted By*