Sign In

Bodies in Balance RMT Massage

PDF  FORM

 

PHYSICIANS REFERRAL 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____________________________________________________________________________________