Referral Form

Patient Name(Required)

First Last

DOB(Required)

Patient Phone(Required)

Referring Practitioner(Required)

Referring Phone(Required)

IR Laser Therapy for Peripheral Neuropathy

Please select the desired options below and provide the requested information:(Required)

*/**Consultation for Chronic Musculoskeletal Pain

**Diagnostic Ultrasound Only

**Therapeutic Ultrasound-guided Injection/Treatment

**Diagnostic Ultrasound with Possible Treatment (use for cyst aspirations, carpal tunnel injections, etc)

Second Opinion/Overread of MSK MRI or CT

IR Laser Therapy for Peripheral Neuropathy

(Includes diagnostic ultrasound and integrative pain assessment with recommendations)

Specify Anatomic Location

Clinical Differential Diagnosis

Specify Desired Treatment

Diagnosis

Specify Anatomic Location

Clinical Differential Diagnosis

Specify Desired Treatment (or designate physician discretion):

** PLEASE FAX THE MOST RECENT CLINICAL NOTES AND ANY PERTINENT LAB, IMAGING OR EMG REPORTS

** PLEASE SEND OR HAVE PATIENT DROP OFF IMAGING DISCS PRIOR TO APPOINTMENT