Prescription Form – Home Advantage Rehabilitation

MEDICAL INFORMATION

Reason of services

Past Medical History

Referring physician's Name

Practice Name

Phone

Diagnosis (for physical therapy)

Other info

PATIENT INFORMATION

Name*

DOB*

Address

Patient Phone*

Physical TherapyOccupational TherapyEvaluate & TreatContinue Therapy

Special ProgramsFull Prevention TrainingCardio/Pulmonary RehabilitationSpinal StabilizationBalance ProgramDME AssessmentResidentialAssessment

ProceduresJoint MobilizationMassageMyofascial ReleaseManual Traction

ExerciseAROMAAROMPROMFlexibilityStrengtheningHome Exercise ProgramGait/AOL Training

ModalitiesMoist HeatIceE-StimTENSUltrasound

Diagnosis/Reason for Referral

Additional Notes (Freq/Precautions)

I CERTIFY THAT PHYSICAL THERAPY IS MEDICALLY NECESSARY

Physician Name

Phone

Physician Signature

Date

About Us

Our therapists are able to provide many tools used in the clinic if it is deemed necessary for treatment of your condition.

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