Burn Rehabilitation Occupational Therapy Referral Form
Patient Name
Date of Birth
MRN / ID
Date of Injury
Referring Physician
Contact Number
Burn Details
Total Body Surface Area (%)
Burn Depth
Burn Location(s)
Current Treatment/Interventions
Relevant Medical History
Occupational Therapy Needs / Reason for Referral
Precautions/Contraindications
Referrer Signature
Date