Physician's Form

Special Needs Foundation of Des Moines County

829 Harrison Ave. Burlington, IA 52601

Phone: (319) 752-8222

*******PHYSICIAN’S AUTHORIZATION FOR AQUATIC THERAPY*******

(TO BE COMPLETED BY PHYSICIAN ONLY)
Physician's Name

First NameLast Name
The Special Needs Foundation Aquatic Committee grants financial assistance to individuals who are physically disabled and would benefit from aquatic therapy on a regular basis. Please describe the patient’s disabilities and how he or she would benefit from aquatic therapy.
How often do you recommend the applicant attend?
Number of Months
Indefinitely?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Physician Signature

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Date

MonthDayYear
Date
*If the patient has a chronic or long-term condition, the physician will need to initial and date annually. *
Should be Empty: