Referring Physician: _______________________________________ Fax: ______________________

To refer your patient to St. Camillus for outpatient services, please print this form, complete the appropriate information and return it to our Admissions Office via FAX: (315) 488-2834.

Patient Name: ___________________________________________ DOB: _____________________

Diagnosis/Reason for Referral: __________________________________________________________________________________

Appropriate blanks (Dx, frequency and duration) must be completed for initiation of therapy.
Please include any additional treatments if needed and a brief medical history. Use additional
pages if needed.


PHYSICAL THERAPY
Evaluate and Treat Evaluate Only

_______ times per week for _______ weeks for: ___________________________________________


OCCUPATIONAL THERAPY
Evaluate and Treat Evaluate Only

_______ times per week for _______ weeks for: ___________________________________________


SPEECH/LANGUAGE THERAPY
SWALLOWING EVALUATION
MODIFIED BARIUM SWALLOW
Evaluate and Treat Evaluate Only

_______ times per week for _______ weeks for: ___________________________________________


Other: __________________________________________________________________________
Evaluate and Treat Evaluate Only

_______ times per week for _______ weeks for: ___________________________________________


MD, PA or NP Signature: ________________________________________ Date: ________________

Please call 488-1500 with any questions. Thank you for referring your patient to St. Camillus
outpatient services.