PHYSICAL THERAPY ONSITE CLINIC REFERRAL FORM
Revised 05/2016
Please complete the form. Type or print legibly.
Patient Information:
First name: __________________________________
Last name: _________________________________________
Street Address: _____________________________________ City: ___________________ Zip Code: __________________
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Preferred Phone: __________________
_____________________(Alternate): __________________ _________________________
Date of birth: ______________________________
Email address: _______________________________________
Person to contact in case of emergency: _____________________________ Phone: __________________________________
Have you been seen in the UPS Onsite Clinic in the past for the same concern? ____ Yes ____ No
If yes, what year? _____
Preferred Appointment Time: Rank in order of preference (1 – 6, 1 being highly preferred, 6 being least preferred. Mark UA for Unavailable.)
(Selected time not guaranteed- As schedule allows)
Select One
Select One
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9:30a.m. ________ 10:30 a.m.________ 11:30 a.m.________
2:30 p.m. ________ 3:30 p.m. ________
Select One
4:30 p.m. ________
To be completed by referring provider:
NOTE: UPS Onsite Clinic is a direct access clinic for non-surgical musculoskeletal/orthopedic concerns and stable neurologic
conditions. Individuals under active medical care will require signed physician referrals.
Referral Date: _________________________
Date of Onset/Injury: _______________
Medical Diagnosis:
Precautions:
Medications:
Reason for referral:
Comments:
Referred by: (printed name)
Address:
Signature:
Email Address:
Phone:
University of Puget Sound Physical Therapy offers PT appointments during Fall Semester between Labor Day and Thanksgiving on
Tuesdays and Thursdays. Patient appointments are scheduled on the hour from 9:30-11:30 am and then 2:30-4:30 pm. We offer specialty
care in orthopedic/musculoskeletal injury or pain, neurologic rehabilitation, and pediatric physical therapy. An Exercise/Wellness group is
available Fall Semester. Seating and wheelchair prescription is offered through a specialty clinical elective course most years. During the
Spring semester, PT appointments are offered on Fridays only in the same appointment hours. Spring Clinic does not provide pediatric
physical therapy or seating and wheelchair prescription. All care is provided by graduate students in physical therapy under the supervision
of licensed physical therapists. Please call the clinic at (253) 879-3281 or email onsiteclinic@pugetsound.edu if you have questions.
SCHOOL OF PHYSICAL THERAPY
1500 N. WARNER ST. # 1070 • TACOMA, WA 98416-1032 • TEL 253.879.3281 • FAX 253.879.3518 • WWW.UPS.EDU/PT