Name ______________________________________________________
D.O.B. _____________
PhONe _________________________________________________________
Date ____/___/____
FrequeNcy _____________________________________________________
DuratiON ________
DiagNOsis
________________________________________________________________________
PhysiciaN
________________________________________________________________________
PhysiciaN’s sigNature
________________________________________________________________
EvaluatE and trEat
Physical theraPy
aquatics theraPy (rOckwall, rOwlett)
VestiBular rehaB / BalaNce traiNiNg
OccuPatiONal theraPy
haND theraPy / custOm sPliNtiNg
Dry NeeDliNg
Other __________________________
PrecautiONs / aDDitiONal iNstructiONs
___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Arlington*817.472.8383
Fax 844.364.1705
BEdford*817.835.8025
Fax 844.813.7801
Carrollton972.492.9451
Fax 844.364.1299
flowEr Mound972.899.2537
Fax 844.364.1305
fort worth817.294.4646
Fax 844.364.1297
frisCo214.619.5401
Fax 888.965.4925
n. lEwisvillE*972.420.6605
Fax 844.364.1306
lEwisvillE - vista ridgE972.395.0500
Fax 844.364.1304
MCKinnEy*972.542.7360
Fax 844.364.1300
north dallas972.662.1700
Fax 844.364.1301
Plano972.781.2322
Fax 844.364.1302
southlaKE817.753.3093
Fax 844.840.7353
thE Colony469.362.2607
Fax 844.364.1303
WWW.GREATERTHERAPYCENTERS.COM Revision Date: 05/20
allianCE817.402.0218
Fax 844.537.3572
MansfiEld 817.473.4684
Fax 866.277.8919
Plano lEgaCy469.277.8477
Fax 844.894.8400
fornEy972.564.2227
Fax 833.234.1857
tErrEll972.524.9100
Fax 833.234.1856
roCKwall972.771.1090
Fax 833.231.7605
rowlEtt972.475.5122
Fax 833.231.7606
Quinlan903.356.4100
Fax 833.234.1855
farMErsvillE972.784.6533
Fax 833.231.7607
MEsQuitE972.288.2400
Fax 833.234.1878
Methodist Mansfield
Methodist Mansfield
Texas Health Southlake Texas Health Southlake
Texas Health Southlake
Texas Health Presbyterian HospitalFlower Mound
Texas Health Presbyterian HospitalFlower Mound
Texas Health Presbyterian HospitalFlower Mound
Methodist McKinney Hospital
Methodist McKinney Hospital
Methodist McKinney Hospital
Methodist McKinney Hospital
Methodist McKinney Hospital
Methodist McKinney Hospital
Methodist McKinney Hospital
Greater Therapy Centers
Texas Health Rockwall
Texas Health Rockwall Texas Health Rockwall
Texas Health Rockwall
Texas Health Rockwall
Texas Health Rockwall
Texas Health Rockwall
ProsPEr469.296.3411
Fax 833.410.3610Methodist McKinney Hospital
arlington *400 west arBrOOk
suite 151PhONe - 817.472.8383
Fax - 844.364.1705
BEdford*2419 highway 121
PhONe - 817.835.8025Fax - 844.813.7801
Carrollton3733 JOsey laNe
suite 100PhONe - 972.492.9451
Fax - 844.364.1299
farMErsvillE1022 state highway 78 NOrth
PhONe - 972.784.6533Fax - 833.231.7607
allianCE12650 N. Beach street
suite 150PhONe - 817.402.0218
Fax - 844.537.3572
flowEr Mound3400 lONg Prairie rOaD
suite 101PhONe - 972.899.2537
Fax - 844.364.1305
fort worth5950 BryaNt irViN rOaD
suite 100PhONe - 817.294.4646
Fax - 844.364.1297
frisCo14660 state highway 121
BuilDiNg a, suite 110PhONe - 214.619.5401
Fax - 888.965.4925
north lEwisvillE*966 NOrth garDeN riDge
suite 530PhONe - 972.420.6605
Fax - 844.364.1306
fornEy1012 east us highway 80
suite ePhONe - 972.564.2227
Fax - 833.234.1858
lEwisvillE - vista ridgEiNsiDe heBrON meDical Plaza751heBrON
Parkway, suite 160
PhONe - 972.395.0500Fax - 844.364.1304
MCKinnEy*2309 VirgiNia Parkway
suite 400PhONe - 972.542.7360
Fax - 844.364.1300
north dallas3423 triNity mills rOaD
suite 520PhONe - 972.662.1700
Fax - 844.364.1301
MansfiEld1497 highway 287 N
ste 101 PhONe - 817.473.4684
Fax - 866.277.8919
MEsQuitE1010 NOrth BeltliNe rOaD
suite 102PhONe - 972.288.2400
Fax - 833.234.1878
southlaKE190 sOuth PeytONVille rOaD
suite 100PhONe - 817.753.3093
Fax - 844.840.7353
rowlEtt5501 gOrDON smith rOaD
suite 100PhONe - 972.475.5122
Fax - 833.231.7606
tErrEll301B sOuth VirgiNia street
PhONe - 972.524.9100Fax - 833.234.1856
thE Colony4713 highway 121
suite 306PhONe - 469.362.2607
Fax - 844.364.1303
* haND theraPy serVices PrOViDeD By certiFieD haND
theraPists
Plano lEgaCy6501 PrestON rOaD
suite 102PhONe - 469.277.8477
Fax - 844.894.8400
Plano3501 miDway rOaD
suite 198PhONe - 972.781.2322
Fax - 844.364.1302
Quinlan8885 highway 34 sOuth
suite BPhONe - 903.356.4100
Fax - 833.234.1855
roCKwall930 west ralPh hall Parkway
suite 120PhONe - 972.771.1090
Fax - 833.231.7605
ProsPEr 1061 N. cOlemaN
suite 140PhONe - 469.296.3411
Fax - 883.410.3610
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