Prescription Form - Northern Arizona Rehabilitation and Fitness

450 South Willard, Suite 106
Cottonwood, AZ 86326
Tel: 928 649-9726 Fax: 928 634-2079

Patient Name:

Patient Phone No.:

Diagnosis:

Frequency: Duration:

ROM Limitations (if any):

Physician Specific Protocol Provided: Yes No
Evaluate and Treat	Health Enhancement Training
Sport Specific Traing:

Physician’s Signature:_______________________________________________

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