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Physicians Referral for Massage Therapy Services
From:____________________________________
Patient Name:______________________________
Address:_________________________________
________________________________________
Insurance Company:________________________
Policy Number:____________________________
Claim Numer:_____________________________
Billing Address:___________________________
________________________________________
Date of Injury:____________________________
Diagnosis:_______________________________
________________________________________
ICD- 9 code (s):___________________________
________________________________________ |
Condition is related to ___MVA___work
injury
___Other injury ___Stress ___other medical condition
Number of sessions to be done: (frequency and duration)________________________________
Send progress report:
____ every week
____every two weeks
____at the completion of prescribed treatments
____other______________________________
Special directions/Comments:___________________
___________________________________________
___________________________________________
___________________________________________ |
Areas to be worked on: (circle all that apply, add comments)
Cranial: Temporalis, Masseter, Frontalis__________________________________________________________
________________________________________________________________________________________
Cervical: E.S, Levator, Scalenes, SCM, Spenius
Cervicus/Capitis, Trapezius, Sub-occipitals____________________
________________________________________________________________________________________
Thoracic: E.S, Rhomboid, Serratus Anterior, Trapezius,
Serratus posterior superior__________________________
________________________________________________________________________________________
Shoulder: Infraspinatus, Supraspinatus, Subscapularis,
Teres , Deltoid, PecMj, PecMn_______________________
________________________________________________________________________________________
Lumbar: E.S, Quadratus, Iliacus, Psoas__________________________________________________________
Sacral: Gluteus Max, Min, Med, Rotators, IT Band,
Quads, Hamstrings, TFL______________________________
________________________________________________________________________________________
Other:___________________________________________________________________________________
________________________________________________________________________________________
Hydrotherapy: None, Heat, Cold Location:______________________________
Physicians Signature____________________________________________________Date:______________
Physicians Name printed:_______________________________________
Address_________________________________________________________________________________
Phone___________________________________________________________________________________
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