Rachele P. Branson, OTR/L, CHT
Certified Hand Therapist
Clinic Owner
Laura Higgins, PT
Women’s Health Physical Therapist
575 Dekalb Industrial Way, Suite 103 · Decatur, GA 30033
Tel 404-296-8511 · Fax 404-296-8514
www.decaturtherapyspecialists.net
Leslie Green PT, MTC
General Orthopedics, Hand Therapy
H a n d T h e r a p y • Wo m e n ' s H e a l t h P hy s i c a l T h e r a p y • O c c u p a t i o n a l T h e r a p y • P hy s i c a l T h e r a p y
Patient:
Date:
Diagnosis:
Precautions:
x per week
Frequency: Evaluation Plus:
x weeks
o Evaluate & Treat
Services
Specialty Programs
Hand Therapy (PT/OT)
Occupational Therapy
Physical Therapy
Procedures
AROM/AAROM
PROM
Strengthening
Soft Tissue Mobilization
Joint Mobilization/Muscle Energy Technique
Scar Management
Edema Control
Wound Care
Home Exercise Program
Breast Cancer Rehabilitation
Cancer Related Fatigue
Osteoarthritis/Osteoperosis
Women’s Health
Pelvic Pain
Pregnancy/Post Partum Pain
Urinary Incontinence
Modalities
E-Stim
TENS (Home Use)
Iontophoresis
Ultrasound
Splinting
Static________________
Dynamic/Static Progressive
Special Instructions:
Physician’s Signature:
DO NOT EMAIL PRESCRIPTION The electronic prescription form is provided for your convenience. With respect to responding to this form,
please do not send the prescription via email. Please populate, print and sign a hardcopy that may be faxed, mailed or hand delivered to the clinic.
Located at 575 Dekalb Industrial Way, Suite 103 at the corner of
Dekalb Industrial Way and North Decatur Road.
JUST A REMINDER:
Please bring this referral slip with you on your first visit.
Please arrive 15 minutes before your scheduled appointment to complete
the necessary paperwork.
WHAT TO BRING:
Please bring your insurance card and/or your authorization referral slip.
Workers compensation employer information including claim number or
no-fault automobile insurance information.
WHAT TO WEAR:
Please wear comfortable clothing that will allow access for treatment.