Referral Form

Referral Form

Services Requested :
(Respiratory Therapy & Physical Therapy Evaluations) Includes 6 minute walk test, Berg Balance, Spirometry, Pulse Oximetry, Monitoring BP/HR/O2, endurance testing, pulmonary hygiene, inhaler training, nutritional counseling, Oxygen Therapy, patient education, smoking cessation, gait training, upper/lower body strengthening, functional training in activities of daily living and self care, and balance training.
Treatment may include: neurological assessment, therapeutic exercises, balance/gait training, neurological and functional training, Vestibular Rehab Therapy, upper and lower body strengthening, musculoskeletal postural assessment and training, pain control modalities (H-Wave, TENS, Cryotherapy, Heat, KT Taping).
Treatment may include: UE/CS/TS hand/shoulder/neck/thoracic assessments; manual therapy, postural and functional upper body strengthening for functional activities of daily living, self-care and pain control modalities.
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Please Forward Patient Medical History Upon Referral
Accepted Insurances on Reverse Side
Thank you for your referral. We will verify the patient's insurance and reach out to get them scheduled.!
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