Physician Referral Form

PHYSICAL THERAPY REFERRAL

Evening & weekend appointments available.

convenient locations:

Liberty Physical Therapy, Inc.

Lincoln, RI 02865 Cranston, RI Pawtucket

872 Smithfield Avenue 1528 Cranston Street 1145 Main Street

FAX: (401)-722-0056 FAX: (401) 228-7218 FAX:(401)722-0056

Patient Name:_____________________ Physician:______________________

Diagnosis: _______________________ Employer:______________________

Insurer: ________________________ Date: ______________________

Most Insurances Accepted, Including but not Limited to:

Aetna · Blue Cross of RI and MA · Cigna · United Health · Medicare

Neighborhood Health ·Workers’ Compensation of RI & MA

Services / Modalities Requested; Please check all that apply:

( ) Evaluate and Treat ( ) Functional Capacity Evaluation

( ) Aquatics ( ) Body Mechanics Training

( ) Trunk Stabilization Training ( ) Graded Work simulation

( ) Joint mobilization ( ) Ergonomic Education/coaching

( ) Proprioceptive Training ( ) Chronic Pain Management

( ) Ultrasound/Moist Heat ( ) myofascial release

( ) Electrotherapy ( ) Soft Tissue Mobilization

( ) Vestibular Rehabilitation ( ) Job site Evaluation

Clinical restrictions/contraindications: _____________________________________

Pertinent diagnostic testing results: _____________________________________

Physician’s Signature:_________________________________________________