Physicians Referral Form for
Massage Therapy

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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