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NATURAL TOUCH
REHABILITATION CENTRE
❑ 312 Queen Street East
❑ 914 Burnhamthorpe Road, West
Brampton, ON L6V 1C2
Mississauga, ON L5C 2S3
Fax:905-796-5100 (B) Te1:905-281-8247 Fax:905-281-1399 (M)
Specialists In:
Chiropractic, Physiotherapy, Massage Therapy, Acupuncture/ Laser, Aquatic Therapy,
Motor Vehicle Rehabilitation, Assessments, Assistive Devices, WSIB, Exercise/ Sports
and General Injuries
Patient Name:
Date
Phone-
Diagnosis:
Re strictions•
❑ WSIB
❑ EXTENDED
❑ PRIVATE
❑ MVA
(Accident Date)
REHABILITATION SERVICES
o Paramedicals: Chiropractic, Physiotherapy, 0
Spinal Decompression
Massage Therapy, Acupuncture/Laser
0
Thermal Compression (Ice/Heat)
O Athletic Therapy
0
Shockwave Therapy
o Balance/Vertigo Assessment and Therapy
0
Personal Training/ Work hardening
o Gait Assessment/ Therapy
O Isokinetic Assessment/ Therapy
O Aqua/ HydroTherapy
REHABILITATIVE DEVICES
O Custom Braces
O Tens/EMS/IFC Units
O Custom Orthotics/ Orthopedic Shoes
O Compression Stockings/ Support Stockings
O Other:
ASSESSMENTS
O Specialists Assessment/ Evaluation (Ortho, Neuro, OT, RN)
O Psychological Assessment/ Counseling
O Pain/ Stress Management Program
O Functional Abilities Evaluation (Return to Work Assessment)
O In Home/ Job Site Assessments
O Work Conditioning/ Hardening Program
o Nutritionist/ Fitness Programs (Full size fitness gym & pool onsite)
OT Intervention
O Other:
Referring Physician (please print)
Physician's Signature
PLEASE CALL OR FAX CLINIC FOR AN APPOINTMENT
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