Patient Referral

Patient Information

Patient Name

First Name

Last Name

Date of Birth

Phone Number

(###)

###

####

ICD-10 Codes

Email Address

Physician Information

Physician First and Last Name

First Name

Last Name

Signature Confirmation

I understand that checking this box constitutes a legal signature for my name listed above confirming that I acknowledge and agree to the above Referral to Whole Body Health Physical Therapy

Email

Phone Number

(###)

###

####

Fax Number

(###)

###

####

Should you like a paper method of referral, click here to download a custom referral sheet for our office, which helps us capture some important information on your patient and provides your patient with information on how to contact us. Once on that page, click "file">"download" to save a copy or just simply press the printer icon in the upper left-hand corner to print the document. We would also be happy to provide you with referral pads at your request. If you have any questions, please call us at 503-223-1856 or e-mail us at info@wholebodyhealthpt.com. You can fax completed forms to 503-223-1765.

What sets us apart?

Thorough musculoskeletal diagnostic skills

Ability to identify red flags that requires a different provider for proper care
Ability to educate patients on tissue healing and the importance of exercises for long-term success
Incorporation of preventative care during treatment (reduce risk of re-injury)
Ability to provide one-on-one care for 40-60 minute treatment times

Clear, concise communication on patient care and progress
State-of-the-art patient portal with videos and direct messaging
We want to work with you - please contact us if you would like to know more information about our clinic and to introduce us to yours!