Physician Referral Form

By completing this form, you are providing Elizabeth Bentz, OTD, OTR/L, RYT-200 with permission to contact the healthcare provider for confirmation of services with OTherapYoga, LLC.

Name of CLIENT

Referring PHYSICIAN or Healthcare Provider

Referring PHYSICIAN EMAIL

Referring PHYSICIAN PHONE

Select Service(s)

OT Evaluation and Treat

Therapeutic YOGA

Tai Chi for Rehabilitation