Script Pad DOWNLOAD FORM HERE OR FILL HERE Patient(Required)Date(Required)Diagnosis(Required)Demographics Attached(Required) Yes NoTreatment Procedures Evaluate and treat for physical therapyTherapeutic Exercise(Required) ROM ROM - Passive ____Weeks ROM - Active-Assistive ____ Weeks ROM - Active ____Weeks Strength Training Aerobic Conditioning Dynamic Trunk Stabilization McKenzie Method Balance/Coordination Back ProgramModalities(Required) Electrical Stimulation Ultrasound NMES Iontophoresis Cold Laser Moist Heat/Cold TENS UnitROM - Passive How Many Weeks(Required)ROM - Active-Assistive How Many Weeks(Required)Active How Many Weeks(Required)Patient Education(Required) Postural Awareness ADL Modification Ergonomic Advice Preventive AdviceManual Therapy(Required) Joint Mobilization Soft Tissue MobilizationSpecialized Services(Required) Mechanical Traction Dry Needling Cupping Aquatic TherapySpecial Instructions/Precautions(Required)Frequency Per Week(Required) 1 2 3 DailyPlease ChooseDuration(Required) 1 2 3 4 5 6Please ChooseNext Office Visit(Required)Choose Attached(Required) X-Ray MRI Physician's Notes Operative ReportPhysician Signature(Required)I hereby certify the above services have beenReminder: Please bring this referral slip with you on your first visit Please arrive 15 minutes before your scheduled appointment to complete the necessary paperwork or access forms online at www.bodyworxpt.com Evaluations (1st visit) usually last 45 minutes – 1 hourWhat to wear: Please wear/bring comfortable clothing and sneakers including T-shirts and shorts or sweatpantsWhat to bring: Driver’s license Current insurance card(s) or workers’ compensation employer information including claim number CALL FOR AN APPOINTMENT: 405-253-5076Fax: 405-253-5683 Email:info@bodyworxpt.com Follow Us
