REFERRAL FORM
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Eval. and Treat
Biomechanical Exam
Crutches
Ankle Orthosis
Elec. Stim.
Infrared
Ultrasound
Massage
Paraffin
Tens Application
Muscle Re-Ed.
Pre-op Eval.
Pain Eval.
Theraband
Hot/Cold Therapy
Whirlpool/Fluido
Ultraviolet Therapy
Jost Compression
Myofascial Release
CPM 1
Work Hardening
Therapeutic Ex.
Manual Muscle Test
Home Visit
Tens Rental
Diathermy
Contrast Bath
Aquatic Therapy
Joint Mobilization-Manip
CPM 2
Gait Training
Kinetic Activity
Func. Capacity Eval.
Iontophoresis/Phonophoresis
Precautions:
Physician's name:
Physician's Phone:
Date:
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