Physician Referral

physician referral

Thank you for your referral.  The following information will be securely transmitted to our Activation Specialist and your Patient will be contacted with 1 business day.   We look forward to providing your Patient with outstanding care and customer service.

Sincerely,
Advanced Physical Therapy of Central Florida

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Physician Referral Form

Today's Date:






Date of Follow Up with MD

Evaluate and Treat *

Please choose as many of the following options as are needed:

Back Pain Solution
Carpal Tunnel Pain Relief
Elbow Pain Solution
Fall Prevention Solution
Foot Pain Solution
Hip Pain Treatment
Joint Replacement Rehabilitation
Knee Pain Solution
Migraine Pain Relief
MS Treatment
Neck Pain Solution
Osteoporosis Solutions
Parkinson's Solutions
Shoulder Pain Solution
Stroke Rehab
TMJ Pain Relief Solution
Other

I will be emailing [email protected] medical information or treatment protocols for this patient.
I am attaching medical information or treatment protocols for this patient to this referral.

Recommended Duration and Frequency

Special Instructions

Please note any special instructions or precautions.

Electronic Physician Signature


Electronic Signature Disclaimer *
By checking this box, I certify that I am the above named provider electronically signing this referral form or a representative there of authorized to make referrals and electronically sign the physician’s name.