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Print a Prescription
Form for your Doctor

 

 

 

Prescription

Rehabilitation Center for Children and Adults
300 Royal Palm Way, Palm Beach FL 33480
(561) 655-7266 Fax (561) 655-3269 info@rcca.org

Patient’s Name: _____________________ Daytime Phone: __________________

Diagnosis: _________________________________________________________

Onset: ____________________________________________________________

Precautions: _______________________________________________________

  __ Physical Therapy
  __ Occupational Therapy
  __ Speech-Language Therapy
 
  _______________________________________________________
  PHYSICIAN’S SIGNATURE & DATE

 


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