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Refer a Patient

    Patient Information

    Parent's name if minor patient

    Date of birth *

    Additional information

    Communication with the patient

    Imaging (X-rays, photos)

    .jpg, .pdf, .txt formats, 10 megabyte maximum

    You're not digital?

    It's easy, just take a picture of your x-ray with a smartphone and email it to yourself. Then download this image to your computer. From this form, select this image. Repeat this procedure for all your x-rays and photos.


    Our team will be happy to help.

      Fields marked with an asterisk (*) are required.