872 Smithfield Avenue                   1528 Cranston Street        1145 Main Street

(401) 722-0012                                   (401) 228-7216                    (401) 722-0012

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

Email: libertypt@onebox.com            website: www.libertypt.com           

                                               

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:_________________________________________________