Prescription/Letter of Referral Template

Date:

Patient:

DOB:

Date of Injury:

Dear Meg Stearns, LMT #26559

• Recommended frequency of massage treatment and duration of treatment (e.g. 1x/week for 12 weeks).

• Areas to be treated and goal of treatment.

• Diagnosis code(s)

• CPT code (97124 or 97140)

Name of provider, office name and telephone number and/or other contact information.