Les Slaughter MMP,LMT,TRT,NCTMB
(702) 807-8137
FAX (702) 658-0883

PRESCRIPTION / LETTER OF REFERRAL
"THE FOLLOWING PRESCRIBED TREATMENT IS MEDICALLY NECESSARY"

DATE_________/__________/________

PATIENT_________________________________________________________

PHYSICIAN_______________________ADDRESS_________________________

PHONE____________________________FAX____________________________

REFERRED TO________________________PHONE_______________________

Anyof the following Physicians' current Procedural Terminology, Procedures and /or modalites, which are within this therapists' scope of practice, training, & / or State & / or Patient's Insurance Policy regulations, may be used as therapist deems necessary during any treatment session.  Normally four units are allowed per visit.  A Unit=15 minute segments of time.  Conditions or prescription may require more units.

PROCEDURES and MODALITIES

97124 Massage Therapy            97140 Manual Therapy Techniques

PHYSICIAN'S DIAGNOSIS OF PATIENT

 346.0 Migraines                                                                                                847.2 Lumbar Sprain / Strain  
784.0 Headaches                                                                                                  848.9 Pelvis (unspecified site) Sprain / Strain
847.0 Cervical, incl. Whiplash injury Sprain / Strain                                                     843.9 Hip & Thigh (unspecified Site)
848.1 Jaw (TMJ & Ligament) Sprain/Strain R___L___            846.9 Sacroiliac Region (unspecified site) Sprain/Strain
723.1 Cervicalgia (pain in neck)                                                                                                      847.3 Sacrum Sprain / Strain
840.3 Infraspinatus Sprain/Strain R___L___                                                         724.4 Lumbosacral Radiculitis R___L___
840.5 Subscapularis Sprain/Strain (muscle) R___L___                               724.3 Sciatica (neuralgia,neuritis) R___L___
840.6 Supraspinatus Sprain/Strain (muscle) R___L___                                844.9 Knee or Leg Sprain/Strain R___L___  
840.9 Shoulder & Arm (unspecified site) R___L___                   845.0 Ankle (unspecified site) Sprain/Strain R___L___
841.9 Elbow & Forearm (unspecified site) R___L___                 845.10 Foot (unspecified site) Sprain/Strain R___L___
842.0 Wrist Sprain/Strain (unspecified site) R___L___                               728.2 Myofibrosis; muscles, ligament, fascia
354.0 Carpal Tunnel Syndrome R___L___                      728.85 Spasm of Muscle_______________________________
842.0 Hand Sprain/Strain (unspecified site) R___L___                                       729.1 Myalgia & Myositis (Fibromyositis)
724.1 Pain in Thoracic Spine                                                            728.9 Unspecified Disorder of Muscle, Ligament, Fascia
847.1 Thoracic (Dorsal ) Sprain/Strain                                                  Other____________________________________


Times per Week________or_______Weeks, or Times Per Month______or______Months, or Total Visits This Script______

Patient to return or call, prior to renewal of prescription

PLAN OF CARE / COMMENTS: 

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PHYSICIAN'S SIGNATURE_____________________________________________ LICENSE#____________________________________