Doctor/Practice Referrals Doctor/Practice Referrals "*" indicates required fields Patient Name*Patient Phone Number*Patient Date of Birth* MM slash DD slash YYYY Patient InsuranceSelect InsuranceNYSHIPAetnaHorizonUnited HealthcareMeritain HealthAnthem BCBSEmpire BCBSCignaOtherOther InsuranceReferring Doctor/PracticeReferring Doctor/Practice Contact InfoReason for Visit:*SelectNeck painShoulder painBack PainSciatica/Radiating PainHip PainKnee painLeg PainLeg Numbness / Heavy, Tired LegsVaricose & Spider VeinsFoot PainWeight LossSleep ApneaMen’s HealthMigrainesInjectionsIV therapyEMG/NCVOtherAdditional Treatment/Symptoms InformationCAPTCHANameThis field is for validation purposes and should be left unchanged.
