About Campus Physical Therapy Center
Campus Physical Therapy Center is an organization of San Francisco Physical Therapists who are dedicated to the care, evaluation and treatment of the musculoskeletal system.
Physical Therapy Forms
Medical Diagnosis Certification
California Laws requiere physical therapists to obtain a Medical Diagnosis prior to initiation of Physical Therapy service. If this legal requirement is not met, we can not provide services to you.
Please ask your treating physician to provide you with the lastest diagnosis in their own format or ask them to simply complete the following referral form. The physical therapist will provide you with an evaluation and treatment plan. Please ask your physician to fax the requested medical diagnosis certification form directly to Campus Physical Therapy Center at Fax: 650.240.1834
Medical Diagnosis Certification Form
Authorization to Disclose Medical Information
This form will authorize your treating physician: primary care physician, orthopedist, chiropractor, dentist, podiatrist, to release your medical information such as progress note, x-ray reports, MRI reports, surgery reports that is pertinent to your medical condition for which you are a seeking a Physical Therapy evaluation and treatment. Please ask your treating physician to fax the requested information directly to Campus Physical Therapy Center at Fax: 650.240.1834
Authorization to Disclosed Medical Information
To the patient: Please bring to your first physical therapy visit your physical therapy referral form that include your medical diagnosis, physician's X-ray report and films, MRI reports and films, Surgery report, EMG reports if they are available to you. Please, bring also confortable clothes to expose the area to be treated.
Minors and Adolescents: If you are a minor or an adolescent seeking Physical Therapy services, your parents have the right to consent to medical care. Therefore, one of your parent must be present at all times during your physical therapy session.
Physical Therapy Outcome Forms
These forms will help your physical therapist to gather information and to better understand your physical impairment, disabilities, and functional limitations.They will help you to reach your best outcome. Your physical therapist will ask you to complete one of these forms during your treatment at Campus Physical Therapy Center.
Optimal Data Collection Form
Oswestry Low Back Pain and Disability Form