ALLIED PROVIDER ORDER FORM

Patient Name *

First Name

Last Name

Date of Birth: (ex: Month, Day, Year: January, 01, 1990) *

MM

DD

YYYY

Physical Therapy

Altman Physical Therapy Center (159 E 74th St, New York, NY 10021)

First Available (Physical Therapist)

Follow-Up - 1x Per Week x 12 weeks

Follow-Up - 2x Per Week x 12 weeks

Follow-Up - 3x Per Week x 12 weeks

Acupuncture

Altman Physical Therapy Center (159 E 74th St, New York, NY 10021)

First Available (Acupuncturist)

Follow-Up - 1x Per Week x 20 weeks

Follow-Up - 2x Per Week x 10 weeks

Psychology

Jonathan Kent, PsyD

First Available (Psychologist)

Follow-Up - 1x Per Week x 12 weeks

Follow-Up - 2x Per Week x 12 weeks

Follow-Up - 3x Per Week x 12 weeks

SCS Psych Evaluation

PNS Psych Evaluation

Preferred Date(s):

MONDAY - AM (MORNING)

MONDAY - PM (AFTERNOONS)

TUESDAY - AM (MORNING)

TUESDAY - PM (AFTERNOONS)

WEDNESDAY - AM (MORNING)

WEDNESDAY - PM (AFTERNOONS)

THURSDAY - AM (MORNING)

THURSDAY - PM (AFTERNOONS)

FRIDAY - AM (MORNING)

FRIDAY - PM (AFTERNOONS)

SATURDAY - AM (MORNING)

SATURDAY - PM (AFTERNOONS)

OTHER - ASK PROVIDER TO SPECIFY

Preferred Location(s):

PARK AVENUE CLINIC - 993 PARK AVENUE

TELEHEALTH

OTHER CLINIC LOCATION - ASK PROVIDER TO SPECIFY VIA EMAILL