Physicians Referral for Massage Therapy Services

Physicians Referral Form for Structural Integration Services

Patient Name:________________________________ Address:_____________________________________ _____________________________________Phone: (____)_________________________________

Insurance Company:___________________________Policy Number:_______________________________Claim Number:________________________________ Billing Address:_______________________________ _____________________________________Phone: (____)_________________________________

Date of Injury:________________________________ Diagnosis:____________________________________ ________________________________________ ICD-9 code(s):________________________________ ________________________________________Condition is related to: ___MVA ___Work injury ___Other injury ___Stress ___Other medical

condition (please describe)_________________ _______________________________________ _______________________________________Structural Integration sessions prescribed: Number_____ Frequency ______ Duration _______Send progress report: ____ every week ____ every two weeks ____ at the completion of prescribed treatments ____ other______________________________ Special directions/Comments:__________________ ___________________________________________ ___________________________________________

Areas of concern: (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, Gluteus Min, Gluteus Med, rotators, IT band, quads, hamstrings, TFL _____________________________________________________________________________________________ _____________________________________________________________________________________________Other:_______________________________________________________________________________________ _____________________________________________________________________________________________

Hydrotherapy: None____ Heat_____ Cold _____ Location:____________________________________________Physicians Signature_________________________________________________Date:_____________________

Physicians Name (printed):_______________________________________________________________________ Address:______________________________________________________________________________________ Phone: (_____)_________________________________________________________________________________