Patient Demographic Information

First Name *

Last Name *

Phone *

Gender *

Social Security Number (SSN)

Date of birth

Address

Street Address

City

State

Country

Postal Code

Ordering Provider Information

Provider Name *

Provider Phone *

Provider Office Address

Fax Number

Provider NPI

Patient Insurance Information

Primary Insurance Coverage

Insurance ID Number

Policy Number

Group Number

Medicare Number

Medicaid Number

Reason for Referral / Special Orders

Services Requested

Share diagnosis, referral reason, and any special requests or comments below. *

Attach relevant documents below (i.e. Face Sheet, Patient Demo, Referral, Insurance Card *

Better yet, see us in person!

We love our customers, so feel free to visit

during normal business hours.

Contact Us

817-385-8888

[email protected]

877-504-7060

310 E Interstate 30 STE B104 A
Garland TX 75043

Hours

Mon - 09:00 am – 05:00 pm
Tue - 09:00 am – 05:00 pm
Wed - 09:00 am – 05:00 pm
Thu - 09:00 am – 05:00 pm
Fri - 09:00 am – 05:00 pm
Sat - Closed
Sun - Closed