025047 Sports-Ortho Rehab Referral

Cook Children’s
SPORTS Rehab Northeast
750 Mid Cities Blvd., Suite 130
Hurst, Texas 76054
(817) 347-2925
Referral Fax: (817) 347-2985
Cook Children’s
Sports Rehab Ft. Worth
1919 Eighth Avenue
Fort Worth, Texas 76104
(682) 885-4063
Cook Children’s
Sports Rehab Mansfield
2000 Matlock Road, Suite 100
Mansfield, Texas 76063
(682) 885-2200
To Schedule an
Appointment
Phone: 817-347-2925
Fax: 817-347-2985
REQUIRED FIELDS: In order for this referral to be processed, all fields must be filled out.
Patient’s Name:
DOB:
Diagnosis:
ICD Code:
Surgery Date
Follow-up with Physician
 PHYSICAL THERAPY
 OCCUPATIONAL THERAPY
 EVALUATE AND TREAT
 MODALITIES AS NEEDED
Priority:
Sex:
 Stat (<24 hours)
 High (<1 week)
 TEACH HOME PROGRAM
 Routine (2-3 weeks)
Specific Modalities (as needed): __________E-Stim_________NMES_______Tens_______(_____Home Unit)_____US_______Phono__________Ionto_______Parraffin
_____________Ms. Biofeedback
RESTRICITIONS/PRECAUTIONS: (brace requirements, ROM limitations, wt. bear, incisional care, general medical)
WEIGHT BEARING STATUS:
 Non-Weight Bearing
 Toe-Touch Weight Bearing
 Partial Weight Bearing
 Full Weight Bearing
 Weight Bearing As Tolerated
Progress to full weight bearing status by:
 Therapist may return patient back to community based physical activities and/or sports when appropriate.
SPECIFIC HIP REHAB
 AVULSION FRACTURE:___________________________________________(LOCATION)
 LABRAL TEARS
SPECIFIC SPINE REHAB
 HERNIATED DISK
 KYPHOSIS / SCHEUERMANN’S DISEASE
 NON OPERATIVE SCOLIOSIS  POST-OP SCOLIOSIS
 POSTURAL DYSFUNCTION
 SPONDYLOSIS / SPONDYLOLISTHESIS
 LEGGS-CALVE-PERTHES
 SLIPPED CAPITAL FEMORAL EPIPHYSIS
SPECIFIC KNEE REHAB
 ACL POST-OP  ACL NON-OPERATIVE/PRE-OP  ACL POST-OP WITH MENISCAL
_______PATELLA TENDON GRAFT _______HAMSTRING GRAFT _________I-T BAND GRAFT
 ANTERIOR KNEE PAIN/ PATELLOFEMORAL PAIN/ CHONDROMALCIA
 POST-OP MENISCAL
 LATERAL RETINACULAR RELEASE
GENERAL REHAB:
Contusion
 ROTATOR CUFF TEAR
 SLAP LESION
 DISLOCATION
 MEDIAL EPICONDYLITIS
 LATERAL EPICONDYLITIS
 OLECRANON FRACTURE
 SUPRACONDYLAR FRACTURE
 UCL SPRAINS
 OSGOOD-SCHLATTER
 PATELLAR INSTABILITY/ DISLOCATION
 PCL
SPECIFIC ANKLE REHAB
 SEVER’S / ACHILLES TENDONITIS
 PLANTAR FASCIITIS
Location:
 LITTLE LEAGUE SHOULDER
 GH INSTABILITY/SUBLUXATION
 IMPINGEMENT
SPECIFIC ELBOW REHAB
 I-T BAND SYNDROME
 MENISCAL
SPECIFIC SHOULDER REHAB
 AC/SC SEPARATION
 GH DISLOCATION
Fracture
Osteochondritis
Sprain
Strain
Special Instructions:
Physician Signature:
Date:
Time:
Print Physician Name:
PRINT OR IMPRINT PATIENT INFORMATION
PTREFER
025047 (03/11) EP
801 Seventh Avenue
Fort Worth, Texas 76104-2796
SPORTS/ORTHO REHABILITATION REFERRAL
SPORTS Rehab
locations
To schedule an appointment,
call
817-347-2925.
Fort Worth
P
P
Cook Children’s Medical Cen
C
Fax all referrals to 817-347-2985.
Fort Worth/Child Study Center
W
W. 7th Ave.
20
S. HENDERSON
RICHMOND AVE.
South Rehab Clinic
To I-35W3
MYRTLE ST.
To I-35W
PARK PLACE AVE.
ALLEN AVE.
MID CITIES BLVD.
D.
Cook Children’s
1919 8th Avenue
South
Rehab Clinic
4
3
MID-CITIES BLVD.
TRID
ARLINGTON AVE.
R.
D
GE
PRECINCT LINE RD.
ARLINGTON AVE.
RICHMOND AVE.
Cook Children’s
Northeast Center Rehab
South
Rehab Clinic
750 Mid Cities Blvd.
BEN
RICHMOND AVE.
Cook Children’s
South
Rehab Clinic
South
Rehab ClinicWINDSOR PL.
1919
8th Avenue
Y.
35W
121
121
Matlock Rd.
Medical Center
MAR
TIN R
360
.
DR
7
28
Cook Children’s
GE
183
121/183
121
360
820
35E
35W
Northeast
Center
DEBBIE LN.
820
Cook Children’s
Medical Center
121
COUNTRY 121/183
CLUB DR.
121
360
WALNUT
CREEK
EXIT
820
121
35W
NE
VI
PE
1
12 GRA
Y.
HW
1
12
E.20BROAD ST.
200
WALNUT
CREEK
EXIT
682
682
183
35E
30
2000
Matlock Rd.,
Ste. 100
30
287
5
35W
820
Cook Child
Cook Children’s
MedicalMedical
Center Ce
820
HW
Y.
Cook Children’s
Medical Center
20
TRID
820
BEN
PRECINCT LINE RD.
30
Cook
Children’s
Cook Child
ren’s
MedicalMedical
Center Center
1919 8th Ave., Fort Worth, TX 76110
.
35E
NE
VI
PE
A
GR
360
(not a scheduling
line) 682-885-2200 phone
682-885-4063 phone
682-885-1878
fax
Northeast
Cook Children’s
682-518-8383
fax
Center
Rehab Services
DR
183
GE
121/183
121
TRID
121
35W
PRECINCT LINE RD.
COUNTRY CLUB DR.
4
287
3 Fort Worth/South Rehab Clinic
Cook Children’s
Northeast Center Rehab
750 Mid Cities Blvd.
BEN
MID-CITIES BLVD.
2000 Matlock Rd., Ste. 100
MID CITIES BLVD.
D.
DEBBIE LN.
1300 W. Lancaster Ave.,. Ste. 106, Fort Worth, TX 76102
20
Children’s
682-885-2190 phone Cook
Northeast Center Rehab
4
750 Mid Cities Blvd.
817-877-0529
fax
MID-CITIES BLVD.
MATLOCK RD.
360
20
MID CITIES BLVD.
N RD
35E
30
2 Fort Worth/Child Study Center
M
ARTI
183
360
820
IN
V
PE
WALN
CRE
EXIT
1
12
HW
1 Fort Worth/Cook Children’s
Medical Center
121/183
E
A
801 7th Ave., Fort Worth,
TX 76104
GR
682-885-4063 phone
682-885-1878 fax
Cook Children’s
20
Northeast
Center
820
WINDSOR PL.
PARK PLACE AVE.
MAR
TIN R
PARK PLACE AVE.
3
Reh
750
Hurs
817
817
817
HENDERSON
PARK PLACE AVE.
5th AVE.
7th AVE.
ARLINGTON AVE.
MYRTLE ST.
MYRTLE ST.
4
To I-35W
6th AVE.
1919 8th Avenue
HENDERSON
5th AVE.
6th AVE.
7th AVE.
8th AVE.
WINDSOR PL.
8th AVE.
ROSEDALE
ALLEN AVE.
E. BROAD ST.
S. HENDERSON
P
PARKParking
PLACE AVE.
To I-35W
820
To I-35W
P Visitor Parking
E Emergency Entrance
Visitor
PARK PLACE AVE.
ROSEDALE
MYRTLE ST.
Cook Children’s
Children’s
Rehab Clinic
2000 Matlock Rd.,
Ste. 100
HENDERSON
V Valet Parking
E
ALLEN AVE.
WEST TERRELL ST.
P
5th AVE.
P Visitor Parking
E Emergency Entrance
Visitor
Parking
30
WALNUT
CREEK
EXIT
6th AVE.
7th AVE.
ST.
Valet Parking
V MYRTLE
E
Cook Children’s
Center
1
M
Medical
V
MYRTLE ST.
COOPER ST.
7th AVE.
WEST TERRELL ST.
8th AVE.
V
PENNSYLVANIA AVE.
7th AVE.
PRUITT ST.
COOPER ST.
1919 8th Ave.,
Fort Worth, TX 76110
682-885-4063 phone (not a scheduling line)
682-885-1878 fax
To I-35W
Cook Children’s
Medical Center
1
To I-35W
30
8th AVE.
PRUITT ST.
8th AVE.
Fort Worth/South Rehab Clinic
287
Visitor
Parking
W. LANCASTER AVE.
PENNSYLVANIA
AVE.
ROSEDALE
PENNSYLVANIA AVE.
P Visitor Parking
E Emergency Entrance
Child Study Center
SUMMIT EXIT
PENNSYLVANIA AVE.
V Valet Parking
E
W
1300 W. Lancaster Ave.
P
To I-35W
30
SUMMIT EXIT
V
2
W. LANCASTER AVE.
Cook Children’s
Medical Center
1
COLLIER ST.
SUMMIT AVE.
WEST TERRELL ST.
820
Cook Children’s
Medical Center
1300 W. Lancaster Ave.
2
30
COOPER ST.
Child Study Center
BALLINGER ST.
35E
S. HENDERSON
183
7th AVE.
121
W. 7th Ave.
PRUITT ST.
COLLIER ST.
121/183
820
COLLIER ST.
P
PENNSYLVANIA AVE.
W. 7th Ave.
PENNSYLVANIA AVE.
1
12
SUMMIT AVE.
HW
Cook Children
To I-35W
SUMMIT EXIT
Y.
M
W. LANCASTER AVE.
Fort Worth/Child Study Center
BALLINGER ST.
e
2
750 Mid Cities
Blvd., Ste. 130
Cook Children’s Medical Center
Hurst,
TX 76054
Fort Worth
30
817-347-2925 phone
Fort Worth/Child Study Center
817-347-2985 fax
1300 W. Lancaster Ave.
Fort Worth
Cook Children’s
Northeast SPORTS
Rehab
35W
121
R
SPORTS
Program
Child
Study
Center Services
Cook Children’s Medical Center
Rehabilitation
8th AVE.
PRECINCT LINE RD.
ap
Gr
in
ev
SUMMIT AVE.
Cook Children’s
Northeast SPORTS
Rehab
.
750 Mid Cities Blvd
R.
ED
DG
TRI
BEN
MID-CITIES BLVD.
MID CITIES BLVD.
D.
360
MAR
TIN R
BALLINGER ST.
Hurst/Northeast SPORTS Rehab
A
20
Arlington