A therapist-only philosophy providing our patients the highest quality of care in the valley.
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Welcome Locations Programs For Patients Meet Our Staff For Physicians
 
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Professional rehabilitation provided by therapists, NEVER a technician or trainer.
12 Convenient Locations
Chandler • Fountain Hills • Sun Lakes • Gilbert • Mesa • Tempe • Scottsdale • Phoenix • Maricopa • Queen Creek • Glendale • Peoria
Patient Date

Patient Phone #

Diagnosis:


Evaluate and Treat
Special Instructions / Precautions:


Special Programs / Treatment

Aquatic Therapy Dry Needling Cancer Recovery Program
VRI
Vestibular Rehab Therapy
Balance Program
TASTM
Tool Assisted Soft
Tissue Mobilization
Iontophoresis
Dexamethasone
4mg/ml sol
LSVT BIG Parkinson's Program Electrical Stimulation Anodyne Therapy

Treatment Plan

Frequency of Treatment
1 2 3 4 5 Visits/Week
Duration of Treatment
1 2 3 4 6 8 Weeks
If you leave this area blank, you are intending for the therapist to complete upon evaluation.


Referred by Dr. Please Print

X Signature

Certification: I certify that I have examined the patient and physical therapy is necessary
on an outpatient basis, that services will be furnished while the patient is under my care,
and that the plan is established and will be reviewed as required.



Fax Referrals To (480) 782-5213 • Or Complete and Email to our Physicians Relations Specialist at FeliciaR@360ptaz.com

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