Please note: We do not accept referrals for “generalized fatigue” or “hormone imbalance.”
Please send all relevant consult notes, lab data, imaging, etc. for your clinical question.
The fax number is (817) 788-8416.
Our EMR will support CCDA transmissions.

Patient Name *

First

Last

Patient Date of Birth *

Patient Phone Number *

Patient Email Address *

Referring Physician *

Referring Clinic Phone Number *

Referring Clinic Fax

Primary Care Physician (if different from referring physician)

Other members of the care team who should receive consult reports

Patient Payment Method *

How Urgent is the Consult? *

Please state your clinical question. *

Email *

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