IHMS - Vermont Physical Therapy Specialists, Vermont Work Hardening, Industrial Rehabilitation Specialists, and Certified Occupational Therapists VT.





Referral Form

Physical Rehabilitation Specialists
dedicated to restoring efficient movement, function, productivity, health and life!

IHMS - Referral Form

Online Patient Referral

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We serve all work shifts and daily flexible scheduling hours can be accommodated.
 

IHMS Patient Referral Form for Medical Providers:

*Required Fields

*Patient's Name:

*Patient's Phone Number:

*Patient's Date of Birth:

*Date of Injury:

*Physician Name:

*Physician's E-mail Address:

*Physician's Telephone:

Preferred contact method:

*Diagnosis:

Treatment:
  Physical Therapy - Evaluate and Treat
  Occupational Therapy - Evaluate and Treat
  Work Hardening/Conditioning
  Job Analysis

Functional Capacity Testing:
  Return to Work as a:  
  General Work Capacity
  Assess Full Effort
  Assess Reliability
  Specific Task Tolerance

Specific Instructions:

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