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107 Edinburgh S Dr, #100ACary, North Carolina 27511

Phone # (919) 678-3286

Fax # (919) 999-2488

3825 Barrett Drive, Suite 101Raleigh, North Carolina 27609

Phone # (919) 758-8022

Fax # (919) 999-2488

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- Physician Referral

Physician Referralrpt_admin2019-05-07T21:58:10-05:00

Physical Therapy Orders

Patient Name*

Phone*

Diagnosis*

Precautions

Evaluate and Treat

MANUAL THERAPY TractionJoint MobilizationSoft Tissue MobilizationStretching

THERAPEUTIC EXERCISE Passive ROMActive Assisted / Active ROMStrengtheningCore StabilizationProprioceptive Training

MODALITIES Moist Heat / IceUltrasoundElectrical StimulationIontophoresis Iontophoresis Dosage

Other

Frequency: times/week

Duration: weeks

I certify that this patient is under my care and requires physical therapy treatment as prescribed above.

Referring Physician* Office Phone*

Printable form with fax instructions

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