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Our prescription form is below...

Myofascial Release Treatment Centers:

www.myofascialrelease.com


Upledger Institute of Craniosacral Therapy:

www.upledger.com/
 
Real Exercise Personal Training Center:
Lake County's most experienced personal trainers since 1977. One-on-one weight training.
www.realexercise.biz/
 

 

Our prescription form:

 

GANFIELD MFR THERAPEUTICS, LTD.

                                       Occupational Therapy/Myofascial Release

 

                        ________________________________________________

                        Patient

 

                        ________________________________________________

                        Working Diagnosis                  ICD-9 Code

 

                        ________________________________________________

                        Precautions

 

                            TREATMENT  PLAN                              

 

                                Comprehensive Myofascial Release

                               

q       Evaluate and Treat _________________________________________      

q  Continue Treatment __________________________________________________

q       Treatment Sessions X ____10  ____15____Other

q      Frequency of Treatment   1   2   3   4   5   days

q     Exercise ____________________________________________________________

Active                     Passive                   Resistive

q       Activities of Daily Living

q       Modalities

q     Hot Packs

q        Cryotherapy

q        Ultrasound

q        Vibration

q       TNS

q       Home Program

q        Splint (describe) _____________________________________________________

 

q       Other ______________________________________________________________

 

__________________________________M.D.

                                __________________________________Address

                                __________________________________Address

                                __________________________________Phone/Fax                                        Date:_____________

                        ________________________________________________

                        GANFIELD MFR                                               Lisa Ganfield,OTR/L, CHT

                                THERAPEUTICS, LTD.                             Licensed Occupational Therapist

                                1125 N Delany Rd.                                       And Certified Hand Therapist

                                Gurnee, IL 60031                                 (847) 244-7070  (847) 244-7071 (Fax)


Ganfield Therapeutics * 1125 N Delany Rd * Gurnee, IL * US * 60031
847-244-7070