Patient

First name *
Last name *
Phone *
Diagnosis
Special Instructions / Precautions
Programs / Treatments
Aquatic Therapy
Sports Medicine
Pelvic Floor Rehab
Graston Technique
McKenzie Method Therapy
Vestibular Therapy
Neuropathy Treatment
Cold Laser Therapy
Balance and Fall Prevention
Dry Needling
TPI Program
Bell's Palsy
Parkinson's Disease & LSVT BIG
Cancer Recovery Program
Frequency of Treatment
Duration of Treatment
Referred by Dr. *
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.