Structural Based Therapy - Medical Referral Form
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Structural Based Therapy

Chiropractic & Advanced Regenerative Recovery

Midtown: 1708 Peachtree St. NW, Ste. 109, Atlanta, GA 30309
Alpharetta/Johns Creek: 3719 Old Alabama Rd, Ste. 400 A, Johns Creek, GA 30022
Phone:(678) 469-4133  |  Email: sbtalphabuckhead@gmail.com
Website:://structuralbasedtherapy.com
Medical Care Referral Form
Patient Information
Pre-Treatment Documentation (Please Attach If Available)
Clinical Indications
Requested Services / Modalities
Chiropractic Care Spinal adjustments, structural alignment, & biomechanical therapy
Class IV Laser Therapy High-power photobiomodulation for deep tissue repair
Focused Shockwave Therapy Targeted acoustic waves to stimulate chronic tendon/bone healing
Extracorporeal Magnetotransduction (EMTT) High-energy magnetic fields for cellular regeneration
Evaluate and Treat Protocol Authorizes a comprehensive clinical intake assessment and execution of a tailored structural plan based on indications
Notes / Special Instructions / Target Body Region
Referring Provider Authorization
Automated System Action: A secure submission receipt and subsequent scheduling status updates will be automatically generated and delivered to the referring email address provided above.