Physicians Referral for Massage Therapy Services
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From:______________________________
Patient Name:________________________
Address:____________________________
SS#________________________________
Date of Birth:_________________________
Insurance Company:___________________
Policy Number:______________________
Claim Number:_______________________
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___________________________________________________________________________________
