<% Dim strClinic, strAddress strClinic = Request("clinic") strAddress = "" _ & "" Select Case strClinic Case "g" strAddress = strAddress _ & "" _ & "" _ & "" Case "t" strAddress = strAddress _ & "" _ & "" _ & "" Case Else strAddress = strAddress _ & "" _ & "" _ & "" End Select strAddress = strAddress & "
Progressive Rehab Network
29525 Ford Road
Garden City, Michigan. 48135
(734) 266-3400
23179 Eureka Road
Taylor, Michigan. 48180
(734) 374-2504
28776 Ryan Road
Warren, Michigan 48092
(586) 582-8668
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PROGRESSIVE REHAB NETWORK
1-800-556-8975
Prescription for Physical Therapy
 Patient Name ______________________________________________ Date ______________________
 Diagnosis ____________________________________________________________________________
 Requested Frequency/Duration of Treatment ________________________________________________
Evaluate And Treat Traction Anodyne Therapy
Hot/Cold Pack Whirlpool ADL Training
Ultrasound Manual Therapy FCE (Functional Capacity Eval)
Electrical Stimulation Therapeutic Exercise Work Conditioning
Iontophoresis Gait Training __________________
 Specify Other Treatment or Special Instructions ______________________________________________
  _____________________________________________________________________________________
  _____________________________________________________________________________________
 Signature ___________________________________________________ Date _____________________
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