Physician Referral Form — TheraFlow Health

🏥 Referring Practice — Part 1 of 6

Physician / Provider Name *

Specialty *

Practice / Clinic Name *

Practice Phone *

Practice Email

Referral Submitted By

Role / Title

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👤 Patient Information — Part 2 of 6

First Name *

Last Name *

Date of Birth *

Biological Sex

Patient Phone *

Patient Email

Preferred Contact Method

Phone call Text message Email Any

Referral Urgency *

Pre-operativePrior to surgery

RoutineStandard scheduling

Within 1 weekPriority scheduling

ASAPUrgent — contact today

At TheraFlow's discretionEva will assess and schedule appropriately

✅ Physician Clearance — Part 4 of 6

Clearance requirement TheraFlow Health requires written physician clearance prior to initiating any clinical service. Clearance confirms that the patient has been evaluated and is medically authorized to receive the requested lymphatic or related therapeutic service. This requirement applies to all referring specialties.

24-hour cancellation policy Clearance documentation must be received no later than 24 hours prior to the patient's scheduled appointment. This window is required to review the patient's clinical history and develop an individualized treatment plan before the patient arrives. Clearance not received within this window will result in appointment cancellation or rescheduling. Please plan accordingly.

Clearing Provider Name *

Credential / Title

NPI Number (optional)

Clearance Date *

Precautions, Contraindications, or Activity Restrictions

Electronic Signature of Clearing Provider *

Typing your full name constitutes your electronic signature and confirms that this patient is medically cleared for the requested TheraFlow Health service(s).

✋ Requested Service(s) — Part 5 of 6

Select all services being requested. Tap a card to select it — a checkmark will appear.

✓

Post-surgical MLD

Specialized Manual Lymphatic Drainage for patients recovering from plastic, orthopedic, general, oncologic, breast, or OB/GYN surgery. Indicated for post-operative edema, ecchymosis, early fibrosis, and impaired lymphatic return. May include swelling and tissue assessment, fibrosis monitoring, garment evaluation, foam or lipofoam placement, targeted decompression, K-taping when appropriate, measurements, photography, and individualized home-care education.

✓

Advanced scar and tissue therapy

Indicated for scar restriction, fibrosis, induration, tethering, banding, adhesions, puckering, or limited ROM following surgery or injury. Particularly effective for facelift and neck lift banding beginning 2–4 weeks post-operatively once all wounds are fully closed. Also appropriate for breast puckering, abdominal restriction, C-section limitation, liposuction-related fibrosis, orthopedic and oncologic scars, and axillary cording. May include manual scar mobilization, tissue decompression, targeted decompression, cryotherapy, thermal therapy, friction techniques, K-taping, compression guidance, and home-care planning.

✓

Compression garment fitting — with garment purchase

Professional anthropometric measurement, garment selection, fit assessment, and patient education when the compression garment is supplied through TheraFlow Health. Includes instruction on wear schedule, pressure distribution, donning and doffing technique, garment care, and foam or lipofoam placement when clinically appropriate.

✓

Compression garment fitting — without garment purchase

Professional fit assessment for patients who have an existing garment or will obtain one independently. Evaluates sizing accuracy, pressure distribution, rolling, digging, poor compression placement, garment style appropriateness, and adequacy of support over the surgical or medical area. $50 fitting fee applies.

✓

Pre-operative or post-operative consultation

Comprehensive preparation or recovery support for surgical patients. Pre-operative consultation may include a Zoom or in-person session with the referring provider or patient, procedure and recovery timeline review, surgeon instruction review, garment and compression planning, foam or lipofoam planning, MLD timing guidance, home environment setup recommendations, recovery supply preparation, scar-care education, and individualized pre-surgical coaching. Post-operative consultation addresses swelling, bruising, fibrosis, garment concerns, foam placement, scar questions, tissue hardness, banding, pulling, and recovery uncertainty.

✓

Lymphedema and lipedema consultation

Comprehensive clinical intake and individualized care planning for patients diagnosed with or presenting symptoms of lymphedema or lipedema. Includes detailed history collection, swelling pattern and tissue assessment, volume measurements, photographic documentation, Complete Decongestive Therapy (CDT) planning and phase breakdown, compression evaluation and garment recommendations, MLD frequency and duration planning, home self-care program, full cost and session outline, and long-term management strategy.

✓

Medical lymphatic care / chronic medical care

Ongoing clinical lymphatic support for chronic edema, post-cancer treatment sequelae, venous insufficiency-related swelling, inflammatory edema, mobility-related fluid accumulation, and long-term lymphatic conditions. May include MLD, serial measurements, tissue assessment, compression guidance, K-taping, integumentary and skin-care education, and individualized home-care planning.

✓

Pregnancy and postpartum MLD

Gentle MLD for gestational and postpartum edema, fluid retention, dependent swelling, and tissue discomfort. Prenatal MLD available during the second and third trimesters with written OB clearance. Postpartum MLD appropriate following vaginal delivery or cesarean section once medically cleared by the patient's delivering provider.

✓

Oncology and breast reconstruction lymphatic care

Specialized lymphatic, scar, and tissue support following oncologic procedures including lymph node dissection (axillary or inguinal), radiation therapy, mastectomy, lumpectomy, breast reconstruction (implant-based, DIEP, TRAM, or latissimus flap), explant, or revision surgery. Addresses post-operative edema, chest wall restriction, axillary web syndrome (cording), scar tethering, limited shoulder ROM, and lymphedema risk reduction.

Additional clinical notes for Eva

📄 Post-Operative Report & Submission — Part 6 of 6

Post-operative / clinical report required To support safe and individualized care, TheraFlow Health requests a copy of the patient's post-operative or clinical report prior to the first treatment session. Documentation must be received at least 24 hours prior to the patient's scheduled appointment.

How will the post-operative report be delivered? *

Secure email to records@theraflowhealth.com Upload directly to TheraFlow's secure Google Drive folder Patient will bring a printed or digital copy to first appointment

Secure document upload

To upload the post-operative report directly, use TheraFlow Health's secure Google Drive folder. Please name the file with the patient's last name and date of surgery before uploading.

📂 Open secure upload folder →

Secured via Google Workspace · HIPAA BAA on file · TheraFlow Health access only

✏️ Acknowledgment & Submission

Acknowledgment * I confirm that the information submitted in this referral is accurate to the best of my knowledge, that the patient has been informed of and has consented to this referral, and that the clearing provider has authorized the requested clinical service(s). I understand that clearance documentation must be received at least 24 hours prior to the patient's appointment or the appointment will be subject to cancellation or rescheduling.

Date of Submission *

Submitted By *

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✅

Referral received

Thank you for referring your patient to TheraFlow Health. Eva Tutic, CLT will review this referral and your patient will be contacted to schedule their appointment.

If post-operative documentation has not yet been submitted, please ensure it reaches TheraFlow Health at least 24 hours before the scheduled appointment to avoid cancellation.

Questions? Contact TheraFlow Health at (757) 719-8772

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