All information shared with DANCE|PREHAB Physical Therapy & Performance is kept strictly confidential. We are committed to protecting patient privacy and ensuring that all records, conversations, and medical details are handled in accordance with professional and ethical standards. Your trust and confidentiality are always respected.

PATIENT REFERRAL FORM

Patient Information

First Name *

Last Name *

Patient Date Of Birth

Guardian First Name (if minor)

Guardian Last Name (if minor)

Phone *

Email

Medical Information

Diagnosis

Date of Injury/Surgery

Precautions or Special Considerations

Physical Therapy Support (Check all that apply)

SERVICES REQUESTED *

Physical Therapy Evaluate & Treat

Performance Training / Injury Prevention

Return to Dance / Sport Testing

TREATMENT OPTIONS *

Manual Therapy

Joint Mobilization

Therapeutic Exercises

Neuromuscular Re-Education

Blood Flow Restriction Training

Balance Training

Gait Training

Taping

Home Exercise Program

Other (please specify below)

If Other, Please Specify

Frequency & Duration

Visits per week
# of weeks

Would you like to upload any additional files?

Imaging Reports, Follow-Up Visit Correspondence

Referring Provider Information

Physician First Name *

Physician Last Name *

Designations

Referring Clinic Name

Office Email

Office Phone

Privacy Policy