Prescription Rehabilitation Center for Children and Adults 300 Royal Palm Way, Palm Beach FL 33480 (561) 655-7266 Fax (561) 655-3269 info@rcca.org Patient’s Name: _____________________ Daytime Phone: __________________ Diagnosis: _________________________________________________________ Onset: ____________________________________________________________ Duration: ___________________________ Frequency: ____________________ Precautions: _______________________________________________________
	__ Physical Therapy
	__ Occupational Therapy
	__ Speech-Language Therapy
__ Hotpack or coldpack __ Mechanical traction __ Electrical stimulation __ Paraffin __ Whirlpool __ Fluidotherapy __ Transcutaneous electric nerve stimulation __ Iontophoresis __ Phonophoresis __ Contrast baths __ Ultrasound __ Therapeutic exercise or strengthening __ Range of motion __ Neuromuscular reeducation __ Balance/Coordination __ Neurodevelopmental treatment __ Sensory Integration __ BTE Workstation __ Pilates __ Aquatic therapy __ Back rehabilitation    __ Balance systems __ Cardiac rehabilitation __ Gait training __ Massage __ Manual therapy __ Orthotic fitting & training __ Splinting __ Prosthetic training __ Therapeutic activities for function __ Self care/home training __ Activities of daily living __ Community/work training __ Wheelchair management __ Supplies __ Cognitive retraining __ Speech or language therapy __ Swallowing or voice therapy __ Other treatment modalities Comments: I certify the above is medically necessary: _______________________________________ UPIN#: _______________ PHYSICIAN’S SIGNATURE & DATE

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