Therapy Referral Form

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Therapy Referral
Therapy Appointments (651) 968-5600
General Information/Directions (651)-968-5200
Blaine • Eagan • Downtown St. Paul • Midway • Vadnais Heights • Woodbury
PATIENT INFORMATION
New Order/Plan of Care
Updated Plan of Care
Patient Name __________________________________ DOB ___________________________
Treatment Diagnosis______________________________________________________________
Date of Injury/Surgery _______________________ Patient is aware of diagnosis and prognosis? Y or N
Insurance ____________________________ Phone (H) _____________(W) ________________
Contraindications / Precautions ______________________________________________________
Bring this prescription and insurance information to your first visit.
EVALUATE & TREAT
Hand Therapy
Physical/Occupational Therapy
Frequency and Duration determined by patient progress and therapist discretion
Up to _______
Visits Frequency / Duration 1 2 3 4 5 x/week for _________ weeks
Up to _______visits
Treatment Goals
+ ROM
+ Strength
- Pain
- Swelling
+ Flexibility
Restore Function
Desensitization
Procedures
Modalities
As Indicated
Range of Motion PROM AROM AAROM
Ultrasound
Edema Control
Phonophoresis (10% Hydrocortisone)
Joint Mobilization
Traction
Manual Therapy TFM MFR STM
Electrical Stim (TENS IFC EGS FES)
Tool Assisted STM (Graston)
Iontophoresis (Dexamethasone 4mg/ml)
Neuromuscular RE-Education
Strengthening
Scar Management
Fluidotherapy
Paraffin
Exercise Programs
Back Rehabilitation / Neck Rehabilitation
Splint / Orthosis
Shoulder Rehabilitation
Elbow Rehabilitation
Describe ____________________________
Wrist / Hand Rehabilitation
Dynamic
Static
Knee Rehabilitation
Elbow
Forearm / Wrist
Hand
Ankle Rehabilitation
Gait Training
Specialty Programs
Strengthening / Conditioning
Home Exercise
Dancers
Runners
Throwers
Posture / Body Mechanics Training
Spinecare
Golf Fitness
Pre-Op Exercise
PROVIDER INFORMATION
Date ___________ Referring Provider Name _______________________________________________
Referring Provider Signature __________________________ UPIN# or NPI# _____________________
Phone _________________________________Fax _______________________________________
5015 (4/15)

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