Physician Referral Form
Please select an office.
If you would like to print and fax this form, please download it Here(opens in a new tab). Once completed, you can fax it to (724) 832-7633.
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Primary Symptoms (Please Check All Applicable)
Primary Symptoms (Please Check All Applicable)
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Testing (Please Check All Applicable)
Testing (Please Check All Applicable)
Ordering Physician
Ordering Physician
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.