Occupational / Physical Therapy Order to Evaluate and Treat
Patient Name _____________________________________________DOB________________Phone_______________________________
Diagnosis Code(s) ____________________________________________________________________________________________________
_____ times per week for _____ weeks _____ as needed (PRN) (optional information below)
FEMALE MALE ORTHOPEDIC REHAB
(Pelvic Floor Programs) (Pelvic Floor Programs)
___Pelvic Floor Strengthening ___Pelvic Floor Strengthening ___Postural Education
___Pelvic Relaxation ___Pelvic Relaxation ___Body Mechanics
___Pelvic Pain ___Pelvic Pain ___General Conditioning
___Bladder Retraining ___Bladder Retraining ___Balance Retraining
___Overactive Bladder ___Overactive Bladder ___Myofascial Release
___Bowel Re-Education ___Bowel Re-Education ___Soft Tissue Mobilization
___Internal Manual Therapy ___Internal Manual Therapy ___Home Exercise Program
___Manual Therapy ___Manual Therapy
___Postural Ed/Body Mechanics ___Postural Ed/Body Mechanics
___Core Strengthening ___Core Strengthening
___Sexual Dysfunction ___Sexual Dysfunction
___Prenatal/Post-Partum Program ___Home Exercise Program
___Diastasis Re-Education
___Home Exercise Program
Additional Instructions/Restrictions/Precautions_____________________________________________________________
___________________________________________________________________________________________________________________________
PRINTED NAME OF PROVIDER _____________________________________________________________________________________
PROVIDER SIGNATURE _________________________________________________________ DATE _____________________________
In making this referral, the provider certifies that the prescribed treatment is medically necessary
4920 E State St. Suite 4 Rockford IL 61108
(ph)815.637.1100 (fx)815.637.1200
motivatetherapy.com