Letter from PT and Physicians` Physical Therapy Orders
WOODBRIDGE SCHOOL DISTRICT
16359 Sussex Highway
Bridgeville, DE 19933
Date
Dear Dr.
Your patient, is a student at
:
This student has an Individualized Educational Plan (IEP), which calls for physical therapy to assist him/her in achieving his/her educational goals. The Woodbridge
School District is legally responsible for providing this physical therapy. The State of
Delaware will only allow a physical therapist to treat an individual for 30 days without a physician’s order. Please complete the attached form to allow the physical therapist to treat the student for the school year. Included on the form are several areas to note special instructions and any recent surgeries the student may have had.
Please take the time to fill out these areas to ensure the student receives appropriate treatment and return the orders in the enclosed envelope.
. If you have any questions, please call the school at
Thank you,
Physical Therapist
ENC
#1209
WOODBRIDGE SCHOOL DISTRICT
P.O. Box 869 Governors Ave.
Greenwood, DE 19950
PHYSICIANS’S PHYSICAL THERAPY ORDERS
Student Name:
Address:
Date of Birth:
Diagnosis:
Please check as appropriate:
Evaluate and treat as indicated for yearly IEP objectives.
Other orders:
Please indicate specific concerns related to therapy:
Precautions:
Surgery Information:
Specific Instructions:
Medications:
Follow Up Appointment:
Physician Signature: Date
#1209
