Comprehensive Outpatient
Rehabilitation Facility
 
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295 1st Street S, Suite 2
Winter Haven, FL 33880-3272
 
 
 
 
 
 
 
 
 
 
 
 
 
 
We Treat the Whole Person,
Not Just the Injury
Person Receiving Physical Therapy, Physical Therap
Physical Therapy, Polk Therapy, Winter Haven, FL
 
 

Physical RX

 
Physical Therapy Referral Form

Patient Name
 
First Name
 
Last Name
 
DOB
Diagnosis
ICD-9
Phone
Alt Phone
Insurance CO
Policy No
Physician Name (Printed)
Evaluate and Treat:
Frequency________________ x per Week for ____________weeks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other Education
Other (Specify)
Weight Bearing Precautions
 
x _________________________________
Physician Signature:
 
____/____/______
Date
 
My signature authorizes this treatment to be medically necessary