Fax/Email our Form
Its’s quick and easy to refer a patient!
- Download the form click here
- Fill out the patient information as well as what location you would like to send patient
- Fax the information over to one of our 4 locations or email to firstname.lastname@example.org
- If sending to Pines location please email to email@example.com
If you do not have a login and password or if your current login and password are no longer working, please contact one of our locations for assistance.