Referral / Therapy Prescription

Physical & Occupational Therapy · Phone (423) 317-7772 · Fax (423) 317-7773

Patient name

Date of birth

Phone

Diagnosis

Follow-up date

Preferred location

Precautions / contraindications

Date of injury / surgery

times a week for weeks

Number of visits:

Evaluate & Treat PT OT Continue Therapy

Decrease pain / swelling Home exercise program Increase ROM Improve mobility / function Increase strength / endurance Gait / balance / proprioception

Cold / hot packs Electrical stimulation Ultrasound TENS unit / HEP Posture stabilization Dry needling

Flexibility PROM / AROM / AAROM Strengthening Functional / sport specific Posture stabilization TMJ

Kinesiotaping Aquatic therapy Vestibular rehab SASTM / soft tissue mobilization Manual therapy / joint mobilization Pelvic health Vision therapy HIIT

Hand therapy Orthotic molding Splinting / casting

Treatment goals / comments

I certify the need for these services furnished under this plan of treatment and while under my care.

Physician name

Signature

Date

Morristown · 325 W Morris Blvd, Ste B

Maryville · 1009 Hampshire Dr

Bean Station · 2250 Broadway Dr, Ste A-1

Newport · 113 Hedrick Dr

Jefferson City · 263 E Broadway Blvd

Rogersville · 900 W Main St

New Tazewell · 410 N Broad St

Johnson City · 2041 Hamilton Pl

Scan to refer

tristarpt.com

info@tristarpt.com

Fax (423) 317-7773