Physicians Trust Luna | Luna Physical Therapy

Submit a prescription

Submit an Rx securely for your patient using the form below. We’ll use this information to contact and onboard your patient to Luna.

Patient First Name

Patient Last Name

Patient Email (if known)

Patient Primary Phone

Patient Secondary Phone (if known)

Zip Code (if known)

DOB

Diagnosis

Desired date of 1st session

Desired # sessions per week / # of weeks

Rx (Precautions, Prehab, Pre-op Home Assessment, etc.)

Physician First Name

Physician Last Name

Clinic Name

Clinic Fax Number

Physician Phone Number

Physician Email

Submit Rx by Fax: (628) 246-8418