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Drake Center


Specialized Medical and Rehabilitative Care

Reclaiming Health. Restoring Hope. Rebuilding Lives.

Outpatient Therapy Prescription

 

Outpatient Therapy Form
Name: DOB: Date:
Diagnosis: Dx Code:
     
     
Surgical Procedure: Onset Date: Precautions:
 
What therapies are needed:
Physical Therapy        
 














Protocol
Modality of choice
Other
Occupational Therapy        
 









Modality of choice
Other
Speech Therapy        
 




Augmentative alternative communication evaluation treatment
Other
  Frequency and Duration        
  Times/Week
for Weeks
         
  Referring Physician: Phone:
 

---- Prescription expires in 90 days ----

 Fax:
   
 
 
 
 
Main Campus: 151 W. Galbraith Rd., Cincinnati, OH 45216, 513.418.2798 option #2, fax 513.418.2550
Drake Rehab at West Chester: 7626 Univeristy Court #201, West Chester, OH 45069, 513.475.7454, fax 513.475.7455
Drake Rehab at Stetson Square: 260 Stetson Street #266, Cincinnati, OH 45219, 513.221.6690, fax 513.221.6693

  • Pain Relief Center