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Get and Sign Outpatient Adult Lymphedema Physical Therapy Referral Form Rusk Med Nyu

Get and Sign Outpatient Adult Lymphedema Physical Therapy Referral Form Rusk Med Nyu

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457. 0 Post-Mastectomy Lymphedema 457. 1 Lymphedema Post-Surgery Other Physical Therapy Evaluation and Treatment including please select Manual Lymphatic Drainage Multi-layer Bandages Therapeutic Exercise Education and Vasopneumatic Compression Pump 20-45mmHg Affected Extremity please select R Arm L Arm R Leg L Leg PrecautionsFrequency/Duration Physician s Name/Specialty Please Print NPI License Number UPIN Physician s address Office Telephone Office Fax Physician s Signature....
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