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277 Indian Head Road
Kings Park NY 11754
Telephone: 631-269-5170
FAX:
631-269-5283
www.KingsParkPT.com
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PHYSICAL
THERAPY REFERRAL
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❑
Office Visit |
❑
Home Visit |
PATIENT:___________________________________________ DATE:____________
DIAGNOSIS:___________________________________________________________
PRECAUTIONS:________________________________________________________ |
❑
Moist Heat
❑
Cryotherapy
❑
Electric Muscle Stim.
❑
Iontophoresis
❑
TENS/NTM
❑
Ultrasound
❑
Manual Traction
❑
Mobilization
❑ Massage
❑ Cyriax
Friction Massage
❑
Myofasial Techniques |
❑
Gait
Training
____NWB ___PWB ___FWB
❑ Exercise
____Active _____Passive
____Active Resistive
❑ Gen.
Cond. Program
❑ Low
Back Program
❑ Williams
Flex
❑ McKenzie
❑
Cerv. Program
❑ Postural
Train./Body Mech.
❑ Evaluation
& Treatment |
| Treatments:
❑
Daily or _______________X/week for _______ weeks
Special Instructions:
❑
Evaluate and Contact Physician
❑
Send progress notes to M.D. Evaluate and Test
_______________________________________________________________________________
Physicians Name (Please Print)
_______________________________________________________________________________
Referring Physicians Signature |