PHYSICAL THERAPY REFERRAL
Evening & weekend appointments available.
convenient locations:
Liberty Physical Therapy, Inc.
(401) 722-0012 (401) 354-6700
FAX: (401)-722-0056 FAX: (401) 354-6702
Email: libertypt@onebox.com website: www.libertypt.com
Patient Name:_____________________ Physician:______________________
Diagnosis: _______________________ Employer:______________________
Insurer: ________________________ Date: ______________________
Most Insurances Accepted, Including but not Limited to:
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 ( ) Massage
( ) Electrotherapy ( ) Soft Tissue Mobilization
Clinical restrictions/contraindications: _____________________________________
Pertinent diagnostic testing results: _____________________________________
Physician’s Signature:_________________________________________________