Prescription/Letter of Referral for Medically Necessary Therapies
Shangri-La Spa


“ THE FOLLOWING PRESCRIBED MASSAGE TREATMENT IS MEDICALLY NECESSARY ”

DATE: ________/________/________

PATIENT:__________________________________________________________________

PHYSICIAN: _______________________________________________________________

ADDRESS: _______________________________________________________________

PHONE: ______________________________ FAX: ______________________________

REFERRED TO: ________________ Shangri-La Spa_____________________________

Phone: __(772) 223-9858___________________


PHYSICIAN’S DIAGNOSIS OF PATIENT

724.5 BACK PAIN
346. MIGRAINES
784.0 HEADACHES
847.0 CERVICAL, Inc. Whiplash Injury Sprain/Strain
848.1 JAW (TMJ & Ligament) Sprain/Strain R__ L__
723.1 CERVICALGIA (pain in neck)
840.3 INFRASPINATUS Sprain / Strain R__ L__
840.5 SUBSCAPULARIS Sprain /Strain (muscle) R__ L__
840.6 SUPRASPINATUS Sprain/ Strain (muscle) R__ L__
840.9 SHOULDER & ARM (unspecified site) R__ L__
841.9 ELBOW & FOREARM (unspecified site) R__ L__
842.00 WRIST Sprain / Strain (unspecified site) R__ L__
354.0 CARPAL TUNNEL SYNDROME R__ L__
842.10 HAND Sprain / Strain (unspecified site) R__ L__
724.1 PAIN IN THORACIC SPINE
847.1 THORACIC (DORSAL) Sprain/Strain
847.2 LUMBAR Sprain/Strain
848.9 PELVIS (unspecified site) Sprain/Strain
843.9 HIP & THIGH (unspecified site)
846.9 SACROILIAC REGION (unspecified site) Sprain/Strain
847.3 SACRUM Sprain/Strain
724.4 LUMBOSACRAL RADICULITIS R__ L__
724.3 SCIATICA (neuralgia, neuritis) R__ L__
844.9 KNEE OR LEG Sprain/Strain R__ L__
845.00 ANKLE (unspecified site) Sprain/Strain R__ L__
845.10 FOOT (unspecified site) Sprain/Strain R__ L__
728.2 MYOFIBROSIS; muscles, ligament, fascia
728.85 SPASM OF MUSCLE____________________
729.1 MYALGIA & MYOSITIS (Fibromyositis)
728.9 Unspecified Disorder Of Muscle, Ligament, Fascia

Other: _________________________________________________________________

Times Per Week: _______ for _______ Weeks.


PHYSICIAN'S SIGNATURE: ________________________________________________