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Patient Referral

Please complete the patient referral form and submit along with any relevant medical records. A member of our team will contact you shortly to facilitate further communication and expedite your patient’s care.

If you need additional assistance, have questions or would like to discuss your patient’s care prior to referral please contact us at 909-793-5999
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Services Requested:

If available:

​​​​​​​Medical Notes/Records

​​​​​​​Imaging

​​​​​​​Lab Work Results

X-Rays


​​​​​​​Guardian Information


​​​​​​​Patient Information

Sex

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