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Physician's Referral

Physician's Name: ___________________________________________________________________________________________ Physician's Address: _________________________________________________________________________________________ Physician's Telephone: (______) ______________________________________________________________________________

I have been treating this patient since________________for the following condition(s):_________________________________

date

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ I have prescribed (specific massage therapy or bodywork treatment) for this patient's condition as follows: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Rx:___________________________________________________times per week for a period of_____________________weeks. Please note that the following considerations/medications warrant special concern: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Should you notice anything unusual or suspicious in the treatment or progress of this patient, please notify my office immediately.

Physician's Signature____________________________________________________________Date_________________________

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