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Campbell River Physiotherapy Req

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<title>Physiotherapy Referral</title>
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<p type="text" class="noborder" style="font-size:30; text-align:center;">PHYSIOTHERAPY</p>


<p style="margin-bottom: 0cm; text-align: left;">

<font size="1"><span style="font-weight: bold; font-style: italic;"> Date:&nbsp;</span>
<input name="TodayDate" class="noborder normaltext" style="width: 150px" oscardb=today type="text"> 
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<input name="WCB"type="checkbox"><span style="font-weight: bold; font-style: italic;"> WCB &nbsp;&nbsp; 
<input name="ICBC"type="checkbox"><span style="font-weight: bold; font-style: italic;"> ICBC &nbsp;&nbsp;
<input name="Other"type="checkbox"><span style="font-weight: bold; font-style: italic;"> Other&nbsp; &nbsp;<br>
</font></p>

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<span style="font-weight: bold; font-style: italic;"> Patient Name: &nbsp;</span>
<input name="PatientName" class="noborder normaltext" style="width: 280px" oscardb=first_last_name type="text">
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<span style="font-weight: bold; font-style: italic;"> DOB: &nbsp;</span>
<input name="DOB" class="noborder normaltext" style="width: 150px" oscardb=dob type="text">
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<span style="font-weight: bold; font-style: italic;"> PHN: &nbsp;</span>
<input name="PHN" class="noborder normaltext" style="width: 120px" oscardb=HIN type="text"> 

</font></p>
 

<p style="margin-bottom: 0cm;" align="justify" ><font size="1"><span style="font-weight: bold; font-style: italic;"> Diagnosis - Reason for Referral: </span></font></p>
<textarea type="text" class="noborder normaltext"style="height:50; width:750; font-size:14px; font-weight:normal" wrap="normal" cols="1" rows="5" id="Diagnosis1" name="Diagnosis"></textarea>


<p style="margin-bottom: 0cm;" ><font size="1"><span style="font-weight: bold; font-style: italic;">Contraindications - Restrictions:</span></font></p>
<textarea type="text" class="noborder normaltext" style="height:50; width:750; font-size:14px; font-weight:normal" wrap="normal" cols="1" rows="2" name="Contraindications">None identified</textarea>


<p style="margin-bottom: 0cm;" ><font size="1"><span style="font-weight: bold; font-style: italic;">Diagnostic Imaging:</span></font></p>
<textarea type="text"  class="noborder normaltext" style="height:50; width:750; font-size:14px; font-weight:normal" wrap="normal" cols="1" rows="2" name="DiagnosticImaging">None ordered as yet</textarea>
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<p style="margin-bottom: 0cm;" class="noborder normaltext">

<font size="1"><span style="font-weight: bold; font-style: italic;">Referring Physician:&nbsp;</span>
<input name="CurrentUser" type="text" class="noborder normaltext" style="width: 220px" oscardb=current_user></font>
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<font size="1"><span style="font-weight: bold; font-style: italic;">MSP: &nbsp;</span>
<input name="CurrentUserMSPnumber"  type="text" class="noborder normaltext" style="width: 80px" oscardb=current_user_ohip_no></font>
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<font size="1"><span style="font-weight: bold; font-style: italic;">Clinic: &nbsp;</span>
<input name="ClinicName"  type="text" class="noborder normaltext" style="width: 215px" oscardb=clinic_name></font>
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</p>

<br>

<p style="margin-bottom: 0cm;"><input name="AtiveLivingCheckbox"type="checkbox">
<font size="2"><span style="font-weight: bold; font-style: italic;">Active Living Physiotherapy</span>&nbsp;&nbsp;
<a target="_blank" href="http://www.activelivingphysio.com/">www.activelivingphysio.com</a><br>
2-2380 South Island Hwy (and Larwood), Campbell River, TEL: (778) 420-0111 </font></p>


<p style="margin-bottom: 0cm;"><input name="CampbellRiverCheckbox" type="checkbox"> 
<font size="2"><span style="font-weight: bold; font-style: italic;">Campbell River Physiotherapy Clinic</span>&nbsp;&nbsp; Klari Varallyai: &nbsp; 
<a target="_blank" target="_blank" href="http://www.campbellriverphysiotherapyclinic.com">www.campbellriverphysiotherapyclinic.com</a><br>
991 Alder St. Campbell River, TEL: (250) 286-1046 </font></p>


<p style="margin-bottom: 0cm;"><input name="RehabMotionQuinsam" type="checkbox">
<font size="2"><span style="font-weight: bold; font-style: italic;">CBI - Rehabilitation in Motion - Quinsam Clinic &nbsp;&nbsp;</span>(downtown by Save-On Foods) &nbsp; 
<a target="_blank" href="http://www.rehabinmotion.com">www.rehabinmotion.com</a><br>
1371 Greenwood St.Campbell River, TEL: (250) 286-9670</font></p>

<p style="margin-bottom: 0cm;"><input name="RehabMotionWillow" type="checkbox"> 
<font size="2"><span style="font-weight: bold; font-style: italic;">CBI - Rehabilitation in Motion - Willow Point &nbsp;&nbsp;</span>
<a target="_blank" href="http://www.rehabinmotion.com">www.rehabinmotion.com</a><br>
2315 S. Island Highway Campbell River, TEL: (250) 923-3773 </font></p>

<p style="margin-bottom: 0cm;"><input name="EpicCheckbox" type="checkbox">
<font size="2"><span style="font-weight: bold; font-style: italic;">Epic Physiotherapy</span>&nbsp;&nbsp;at RiverCity Therapeutic Centre: &nbsp;&nbsp;
<a target="_blank" href="http://www.epicphysiotherapy.ca">www.epicphysiotherapy.ca</a><br>
Unit 212-1720 14th Ave. Campbell River, TEL: (250) 287-4640</font></p>

<p style="margin-bottom: 0cm;"><input name="MountainviewCheckbox" type="checkbox">
<font size="2"><span style="font-weight: bold; font-style: italic;">Mountain View Therapeutics</span>
<br>111 - Unit C Dogwood St, Campbell River, TEL: (250) 203-5897, FAX: 1-888-567-0833</font></p>

<p style="margin-bottom: 0cm;"><input name="RiverCity" type="checkbox">
<font size="2"> <span style="font-weight: bold; font-style: italic;">River City Physiotherapy</span>&nbsp;&nbsp; 
email:&nbsp;<a href="mailto:rivercityphysio@gmail.com">rivercityphysio@gmail.com</a> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
<a target="_blank" href="http://www.rivercityphysio.com/">www.rivercityphysio.com</a><br>
Providing home visit physiotherapy at client's residence, TEL: (250) 203-4047</font></p>

<p style="margin-bottom: 0cm;"><input name="Seafarer" type="checkbox"> 
<font size="2"><span style="font-weight: bold; font-style: italic;">Sea-Farer Physio</span> &nbsp;&nbsp; 
email:&nbsp;<a href="mailto:drrehabphysio@outlook.com">drrehabphysio@outlook.com</a> &nbsp;&nbsp; 
<a target="_blank" href="http://www.seafarerphysio.com">www.seafarerphysio.com</a><br>
1003 Island Highway (on the docks at Coast Harbour Marina beside Dockside Fish & Chips), TEL: (250) 203-5897</font></p>

<p style="margin-bottom: 0cm;"><input name="TheJoint" type="checkbox"> 
<font size="2"><span style="font-weight: bold; font-style: italic;">The Joint Physiotherapy and Pain Treatment Center </span>&nbsp;&nbsp; 
email:&nbsp;<a href="mailto:thejointphysiocr@gmail.com">thejointphysiocr@gmail.com</a><br>
Suite 107- 250 Dogwood St. Campbell River, TEL: (250) 287-3530</font></p>

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<span style="font-weight: bold; font-style: italic;">Signature &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span></font></p>
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