Doctor Referral Form

Enclosed are referral forms for chiropractic and/or physical therapy. These forms can be printed off and filled in to accompany your patient's first visit to our office.

Print and Fax to:
Kelly Miller D.C.
(816) 523-4724

Date of Initial Consult:
________________________
Appointment Time:
________________________
Referring Doctor:
________________________
Phone Number:
________________________
Diagnosis:
___________________________________________________
History/Comments:
___________________________________________________
  ___________________________________________________
  ___________________________________________________
(__)
Evaluation & treatment as indicated
(__)
See ______ Times a week for _______ weeks
(__)
Send a report of your findings & plan of care to my office
(__)
Per my specific order please perform:
DR:________________________________________

WALDO REHABILITATION, HEALTH & WELLNESS
7337 Broadway Kansas City, MO 64114
Phone: (816) 523-4600 • FAX: (816) 523-4724
www.drkellymiller.com