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 InsuranceNYSHIPAetnaHorizonCignaUnited HealthcareMeritain HealthAnthem BCBSEmpire BCBSOtherOther Insurance Referring Doctor/Practice Referring Doctor/Practice Contact Info Reason 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 InformationCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
