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Referral Form

Thank you for your kind referral. Please fill in the fields below and press "Submit Referral". Your online information will be sent through a secure connection. Our office will contact your patient within the next few office hours to make an appointment.

Patient Details

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Please note that we must be made aware in your clinical summary, the urgency of the patient's situation.

If your patient is showing signs of any of the following symptoms (Symptom 1, Symptom 2, Symptom #3, Symptom #4) please call this number before submitting your referral. If your patient doesn't yet show signs of these symptoms, please continue completing your patient referral and we will come back to you as soon as possible.

Thanks for your referral!

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