ADVANCED REHABILITATION CLINICS, INC.
PHYSICAL THERAPY ORDERS

PATIENT NAME__________________________________DATE________________

DIAGNOSIS (ICD9 Code)_________________________________________________

SPECIFIC REQUEST/PRECAUTIONS/SPLINTS____________________________

________________________________________________________________________

Evaluate and Treat

Frequency/Duration:
at therapist’s discretion
______ times per week for _______ weeks

Additional Instructions:______________________________________________

________________________________________________________________________

 

 

Physician Name:____________________________________

Physician Signature:_________________________________

IN MAKING THIS REFERRAL, PHYSICIAN CERTIFIES THAT PRESCRIBED REHABILITATION IS A MEDICAL NECESSITY.

ADVANCED REHABILITATION CLINICS, INC.
ARC - Advanced Rehabilitation Clinics Inc.
Physical Therapy, Orthopedic Physical Therapy and Rehabilitation Clinics
in Chicago and Suburbs
533 W. North Avenue, Suite 202, Elmhurst, IL 60126 (630) 832-6919 Fax (630) 832-6928
800 S. Wells Street, Suite M-5, Chicago, IL 60607 (312) 431-7610 Fax (312) 431-7644
137 Plaza Drive, Westmont, IL 60559 (630) 323-8646 Fax (630) 323-8656
3540 Seven Bridges Drive, Suite 240, Woodridge, IL 60517 (630) 968-3154 Fax (630) 968-3224
1 Tower Lane, LL, Oakbrook Terrace, IL 60181 (630) 954-0492 Fax (630) 954-0493
77 West Wacker, Mezzanine 3, Chicago, IL 60601 (312) 201-0467 Fax (312) 201-0469
8750 W. Bryn Mawr, Chicago, IL 60631 (773) 864-9452 Fax (773) 864-9448
4225 Naperville Road, Lisle, IL 60532 (630) 577-6920 Fax (630) 577-6930