Doctor Referral Form Referral Form Referral Form Patient's Name: Date of Birth: Phone No: Insurance: Diagnosis: Does Patient Require Oxygen? No Yes if yes, (LPM: ) Services Requested : Pulmonary Rehabilitation: Evaluation & Treatment (Includes Respiratory Therapy and Physical Therapy/Occupational Therapy Evaluations) Includes 6 minute walk test, Berg Balance, Spirometry, Pulse Oximetry, endurance, pulmonary hygiene, gait training, upper/lower body strengthening, functional training in activities of daily living and self-care. Physical Therapy: Evaluation & Treatment Treatment may include: balance/gait training, therapeutic exercise, vestibular therapy, manual therapy, upper and lower body strengthening, musculoskeletal postural and functional assessment/training, neuro-rehab, pain relief, modalities. Occupational Therapy: Evaluation & Treatment Treatment may include: therapeutic exercise, hand/shoulder/neck assessments, manual therapy, upper body strengthening and coordination, activities of daily living, self-care, cognition and modalities. Precautions/Instructions: Physician Name: Physician Phone No: Physician's Signature: Clear Signature Date: Please Forward Patient Medical History and Insurance Information Upon Referral Thank you for your referral. We will verify the patient's insurance and reach out to get them scheduled.! There was an error submitting the form. Please try again. Submit Referral
