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Referral Form
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Referral Form
Referral Form
Patricia Delzell
2022-06-28T12:28:37-04:00
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IR Laser Therapy for Peripheral Neuropathy
Please select the desired options below and provide the requested information:
(Required)
*/**Consultation for Chronic Musculoskeletal Pain
**Diagnostic Ultrasound Only
**Therapeutic Ultrasound-guided Injection/Treatment
**Diagnostic Ultrasound with Possible Treatment (use for cyst aspirations, carpal tunnel injections, etc)
Second Opinion/Overread of MSK MRI or CT
IR Laser Therapy for Peripheral Neuropathy
(Includes diagnostic ultrasound and integrative pain assessment with recommendations)
Specify Anatomic Location
Specify Anatomic Location
Clinical Differential Diagnosis
Specify Desired Treatment
Diagnosis
Specify Anatomic Location
Clinical Differential Diagnosis
Specify Desired Treatment (or designate physician discretion):
*PLEASE FAX THE MOST RECENT CLINICAL NOTE AND ANY PERTINENT LAB, IMAGING OR EMG REPORTS
**PLEASE SEND OR HAVE PATIENT DROP OFF IMAGING DISCS PRIOR TO APPOINTMENT
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