PHYSICAL THERAPY ONSITE CLINIC REFERRAL FORM
Revised 05/2016
Patient Information: Please complete the form. Type or print legibly.
First name: ______Last name: ______
Street Address: ______City: ______Zip Code: ______
Preferred Phone: Home/Cell ______(Alternate): Home/Cell/Work______
Date of birth: ______Email address: ______
Primary Care Provider: Name: ______Phone: ______
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. Mark UA for Unavailable.)
(Selected time not guaranteed- As schedule allows)
2:30 p.m. ______3:30 p.m. ______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:Email Address:
Signature: / 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 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