Patient

First name *
Last name *
Phone *
Diagnosis
Special Instructions / Precautions
Programs / Treatments
Certified Hand Therapy
Fall Risk Screening
FCE/Ergo Science
Work Conditioning Hardening
Aquatic Therapy
Sports Medicine
Graston Technique
Vestibular Therapy
Balance and Fall Prevention
Dry Needling
Bell's Palsy
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.