Refer a Patient

Patient Information:

This completed form serves as a medical script which is required to schedule a patient appointment.

Referring Provider Information

This site is secured and any documents accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents. This form is authorization for use or disclosure of Protected Health Information. By selecting the "Submit" button, you are signing this Form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "Submit" you consent to be legally bound by this Agreement's terms and conditions.