Referring to Which Practitioner
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Dr. Amit M. Patel
Dr. Hunter Allen
Dr. Pooria Fallah
Dr. Asfia Husain
Dr. Min-Yin Li
Dr. Youstina Mikhail
Any
Referring to Which Location
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Arygle, TX
Carrollton, TX
Dallas/Highland Park, TX
Denton, TX
Flower Mound, TX
Fort Worth/Keller, TX
Frisco, TX
Any
Doctor's Name
*
Doctor's Phone
*
Doctor's Email
*
Patient's First Name
*
Patient's Last Name
*
Patient's Mobile Phone #
*
Patient's Email
*
Reason for Referral?
Medical Concerns?
Patient's Treatment Completed
Date Completed
Type of Radiographs?
Date of Last Radiographs?
Patient's Insurance Company
Tentative Treatment Plan?
File
Submit Referral