 |
Alliance Therapy Services |
|
12320 Hwy. 44, Building 3-F, Gonzales, LA 70737
|
| PHYSICIAN REFERRAL FORM |
| (225) 647-9505 • Fax (225) 647-9503 |
| |
Patient Name ______________________________________________________________________
|
Phone #___________________________________________________________________________
|
Diagnosis: _________________________________________________________________________
|
_________ PT _________ Hand _________ OT _________ Speech _________ ASTYM
__________________________________________________________________________________
|
__________ Evaluate and Treat _________ Continue Therapy
|
_________ Specific Order
|
_________ Therapeutic Exercise _________ Electrical Stimulation
|
_________ Massage _________ Phonophoresis
|
__________ Ultrasound __________ ASTYM
|
_________ Moist Heat _________ Iontophoresis
|
COMMENTS ___________________________________________________________________
|
______________________________________________________________________________
|
Frequency Duration _________ x week for _________ weeks
|
| _________________________________ ___________________ |
Physician's Signature Date
_________________________________ |
| Print Physician's Name |
| « Please fax order to our office |
