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How to refer a patient

Physician's referral

Complete this form to begin the patient referral process.

Information about the Referring Physician (Optional fields have been clearly marked)
Title
First Name
Last Name
Name of Hospital or Clinic
Tell us about your medical practice
Country
Contact phone
Office fax (optional)*
Physician’s Email

Information about the Patient (Optional fields have been clearly marked)
First Name
Last Name
Date Of Birth
Gender	Male Female
Address
Country
Daytime phone
Evening phone
Patient 's E-mail (Optional)*

Diagnosis Information
Diagnosis & Treatment
Date of diagnosis

Additional Information

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Health Information

Diabetes mellitus is a chronic disease caused by the inability of the pancreas to produce insulin or to use the insulin produced in the proper way. Diabetes is the 7th leading cause of death among Americans; over » more


	Health News Ibuprofen May Increase Heart Attack Risk The new study, led by Julia Hippisley-Cox, MD, MRCP, of the University of Nottingham, England, did show that Vioxx increased the risk of heart attack by 32% when taken in the previous three months. But it also linked ibuprofen -- brand names » more

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