Doctor Referral Form

Referral Form

Patient's Name:

Date of Birth:

Phone No:

Insurance:

Diagnosis:

Does Patient Require Oxygen?

Yes

if yes, (LPM: )

Services Requested :

Pulmonary Rehabilitation: Evaluation & Treatment

(Respiratory Therapy & Physical Therapy Evaluations) Includes 6 minute walk test, Berg Balance, Spirometry, Pulse Oximetry, Monitoring BP/HR/O2, endurance testing, pulmonary hygiene, inhaler training, nutritional counseling, Oxygen Therapy, patient education, smoking cessation, gait training, upper/lower body strengthening, functional training in activities of daily living and self care, and balance training.

Physical Therapy: Evaluation & Treatment

Treatment may include: neurological assessment, therapeutic exercises, balance/gait training, neurological and functional training, Vestibular Rehab Therapy, upper and lower body strengthening, musculoskeletal postural assessment and training, pain control modalities (H-Wave, TENS, Cryotherapy, Heat, KT Taping).

Occupational Therapy: Evaluation & Treatment

Treatment may include: UE/CS/TS hand/shoulder/neck/thoracic assessments; manual therapy, postural and functional upper body strengthening for functional activities of daily living, self-care and pain control modalities.

Precautions/Instructions:

Physician Name:

Physician Phone No:

Physician's Signature:

Date:

Please Forward Patient Medical History and Insurance Information Upon Referral

Thank you for referring to La Mesa Rehab

We look forward to working with you!

Thank you for your referral. We will verify the patient's insurance and reach out to get them scheduled.!

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