PROVIDER RESOURCES

Provider Referral Form

Patient First name *

Patient Last name *

Patient Phone Number *

DX Codes

DX

Therapy Visits

Duration of Treatment

Therapy Required

Evaluate & Treat

Physical Therapy Evaluation

Chiropractic Evaluation

MedX Lumbar Spine Strengthening

MedX Cervical Spine Strengthening

Core Strengthening/Stabilization

VAX-D (Non-surgical Vertebral Axial Disc Decompression)

Notes:

Physician Name *

Referring Clinic

Services

Physical Therapy
Chiropractic Care
MedX Specific Spinal Testing and Rehabilitation
VAX-D Non-Surgical Spinal Disc Decompression Therapy
Dry Needling
Spine Fitness Membership Program
Telehealth Physical Therapy

Treatments

Lower Back Pain
Neck Pain
Herniated Disc
Pinched Nerve
Bulging Disc
Headaches and Migraines
Vertigo
Shoulder Pain

Carpal Tunnel Syndrome
Knee Pain
Ankle Pain
Hip Pain
Elbow Pain
Wrist Pain
Auto Accident
Sports Injury

Areas Served

Ahwatukee
Chandler
Gilbert
Mesa
Phoenix
Scottsdale
Tempe

Sitemap

About Us
Accepted Insurances
Candace Raczkowski, PT, DPT
B. Jeffrey Jolley, D.C., D.A.C.N.B.
Blog
Home
Patient Success Stories
Frequently Asked Questions (FAQ)
Sitemap
Request An Appointment

2220 S. Country Club Drive Suite 102 Mesa, Arizona 85210

Monday	7:30am - 12:00pm, 1:00pm - 6:30pm
Tuesday	7:30am - 12:00pm, 1:00pm - 6:30pm
Wednesday	9:00am - 12:00pm, 2:00pm - 5:00pm
Thursday	7:30am - 12:00pm, 1:00pm - 6:30pm
Friday	7:30am - 12:00pm, 1:00pm - 6:30pm

Review Us On Google

Follow Us!

© 1999 – 2021 The Center For Total Back Care | All Rights Reserved | Privacy Statement