Physiotherapy referral

A professional referral pathway that supports continuity of care.

Corné Swart Physiotherapy welcomes referrals from doctors and practitioners who value thoughtful communication, patient-centred treatment, and strong rehabilitation follow-through.

Download Referral Form PDF Refer a Patient

Collaborative care

Referrals are handled with respect for the wider treatment context and the patient’s ongoing clinical needs.

Clear documentation

The referral form is designed to be clean, practical, and easy to use in a clinical setting.

Easy to download

A printable A4-style referral form is available as a PDF for quick practice workflow use.

Referral form preview

A clean, printable referral template based on the provided practice workflow

This preview mirrors the downloadable PDF and keeps the layout clear for everyday practitioner use.

Corné Swart Physiotherapy

Prak Nr. 1136666

Physiotherapy Referral

Date

Patient Name

ICD10 Code

Reason for Referral

Sports injury

Pain Management and pain neuroscience education

Chronic pain

Rehabilitation

Muscle spasms

Headaches

Temporo-mandibular joint pain

Lymphatic drainage

Mastitis

Neurological rehabilitation

Bell’s Palsy

Musculoskeletal injury

Lumbar pain

Neck pain

Pelvic and SIJ pain

Shoulder

Hip

Knee

Ankle

Other

Notes

Referring Practitioner

Hartenbos

36 Kaap de Goede Hoop Avenue, Hartenbos, Mossel Bay, 6520

Mossel Bay

Cnr Melkhout Street & Louis Fourie Road, Heiderand, Mossel Bay, 6506

Klein-Brakrivier

33 Brinkley Street, Klein-Brakrivier, 6503

Contact

Phone: 061 504 6187

Email: corneswartphysiotherapy@gmail.com

Download Referral Form PDF